GASTROINTESTINAL

AND ABDOMINAL
IMAGING

Radiodiagnosis department
Imaging modalities in GIT:

 Plain x-ray :
 Ultrasound.
 Luminal Contrast studies.
 Computed tomography (CT).
 Magnetic resonance imaging (MRI).
Technique selection:
Clinical indication and the efficacy of the
technique:
 Most common upper GIT complaints:
dysphagia, dyspepsia, upper
gastrointestinal bleeding, and evaluation of
obstruction.
 The most common diseases are
esophageal and gastric malignancies and
peptic stricture or ulcer.
Technique selection:
 Currently, endoscopy is the most
common method for examining the upper
gastrointestinal tract.
 The radiographic examination can
effectively detect malignancies, peptic
stricture, esophageal mucosal ring, more
severe forms of reflux, and peptic ulcers
larger than 5 mm in size.
COMMON PATHOLOGIES
AND THEIR
PRESENTATIONS.
I. DYSPHAGIA AND ITS
CAUSES
Benign stricture

 Smooth
 Zone of transition :
tapering
 Moderate to marked
dilatation
 Causes: caustic ,peptic
 Thin, annular
narrowing at the
lower end of the
esophagus.
A lower esophageal
mucosal ring
Malignant stricture
 Abrupt Shouldering
 Mild to moderate
dilatation above
 Irregular outline
 Mucosal destruction
and intraluminal
filling defects .
 The annular,
irregular focal
narrowing of the
esophagus with
abrupt margins is
characteristic of
a carcinoma.
Malignant stricture
Achalasia

 Narrowing of the lower

end of the esophagus :
parrot peak appearance
.
 Dilated esophagus with
air fluid level
 Absence of gas in the
stomach
 Tapered narrowing at
the lower end of the
esophagus, and
esophageal dilatation
are features of
achalasia.
Sliding hiatus hernia
 Pouch of the stomach
more than 2 cm above
the hiatus .
 Presence of 3 or more
gastric folds
 +ve reflux .
Paraoesophageal hernia
 Less frequent
 Gastro-esophageal
junction below the
diaphragm
 Presents by chest pain
&bleeding
(Incarceration).
II. UPPER GI BLEEDING
AND PAIN AND ITS
CAUSES
 Epigastric pain and
occult blood in the
stool.
 A smooth barium
collection projects
from the lesser
curvature of the
stomach with a lucent
“collar” at the neck of
the collection, most
consistent with benign
gastric ulcer
 Postprandial epigastric
pain and occult blood
in the stool.
 The central collection
of barium in the
duodenal bulb;
duodenal ulcer with
surrounding edema.
Gastric neoplasm:
 They show a wide
variety of morphologic
forms that include
ulcerative, polypoid,
infiltrative, or mixed
varieties, depending on
the type of tumor.
 They may be small and
polypoid or large lesions
and reveal malignant
features, such as local
invasion and metastases.
 Epigastric pain, weight
loss and anemia.
 A polypoid lesion in the
stomach is most likely a
gastric neoplasm; the
presence of a left lobe
liver metastasis (arrow)
would suggest a
malignancy;
SMALL BOWEL
Small intestine:
 The following luminal contrast methods
can be used to examine the small
intestine: (1) per-oral small-bowel series
(least effective);
 (2) enteroclysis; and
 (3) CT and MRI enterography or
enteroclysis.
COMMON PATHOLOGIES
AND THEIR
PRESENTATIONS.
Small-bowel obstruction
Findings in plain X ray:
 Multiple air fluid levels (>3).

Normal
CT findings:
Peritoneal
adhesions
 CT examination
demonstrates a
caliber transition
(arrows) without
an associated
“mass effect”
suggesting
adhesive small-
bowel
obstruction.
 Abdominal hernias
 External hernias are
the most common
types.
 A small-bowel loop is
contained within an
external anterior
abdominal wall hernia
with narrowing of the
lower small-bowel
loop
Crohn’s disease
 Skip lesions
 narrowing and
irregularity of
several
segments
 Deep ulcers
 Can affect any
part of the
gut.
 A 24-year-old
woman presents
with intermittent
abdominal pain,
diarrhea, and anemia.
 The segmental and
enhancing wall
thickening in the
ileum is most
consistent with
Crohn disease.
Ischemic disease of the small intestine

Portal venous Pneumatosis

gas intestinalis
Neoplasms:

 Axial CT image of
the carcinoid tumor,
and the stellate
desmoplastic
response is evident.
LARGE BOWEL
 The major indications rectal bleeding,
suspicion of inflammatory bowel disease,
neoplastic disease, and evaluation of
colonic obstruction.
 The most common diseases causing
colonic bleeding are diverticulosis,
ischemic colitis, larger colonic polyps, and
carcinoma.
 Luminal contrast studies as barium enema
& CT examination can be used.
COMMON PATHOLOGIES
AND THEIR
PRESENTATIONS.
Carcinoma
 The features most suggestive
of ulcerative colitis are
continuous disease with
rectal involvement, and
ahaustral shortening of the
Double-contrast radiograph of the
colon.
rectosigmoid region shows a
small, smooth, sessile adenoma
(arrow) and a larger pedunculated
(interconnected arrows) adenoma
(arrowhead) more proximally
Diverticular disease of the colon
 Grossly-dilated
loop of large
bowel has a
'coffee-bean shape'
and the
descending colon
tapers in its
inferior portion.
Sigmoid volvulus.
Coronal CT image
showing a right colon
volvulus with the twist in
the ascending colon
(arrow) causing marked
distention of a portion of
the ascending colon (AC)
and the cecum (C). L,
liver.
LIVER, BILIARY TRACT
AND PANCREAS
Diffuse Hepatocellular Disease
 CT is probably the first study used to
survey the liver.
 Ultrasound may have an application.
 MR imaging may be the most sensitive
modality for detecting and characterizing
diffuse diseases of the liver.
 The overall size of
the liver is small.
 The contour of
the liver is
nodular, which is
characteristic of
cirrhosis.
 Recanalized
paraumbilical vein
(arrow), which
indicates portal
hypertension
 Disproportionate
enlargement of
the caudate lobe
(C), as well as
multiple
collateral venous
channels in the
porta hepatis
(arrowhead).
Cirrhosis.
 T2-WI MRI
showing diffuse
heterogeneity
due to
innumerable tiny
low signal
intensity nodules,
regenerative Also note cholelithiasis
nodules (arrow) and
containing splenomegaly (S).
fibrous tissue
and iron.
 Large liver palpated by physical examination.
 Marked diffuse low density when compared
with the spleen, and there is no mass effect on
the vessels.These are findings of fatty liver
 Budd-Chiari syndrome is a condition
involving obstruction of the hepatic veins
or the intrahepatic inferior vena cava.
 The liver is congested and has a mottled
appearance (nut meg) on CT due to the
interstitial edema, especially after
administration of IV contrast material.
Focal Hepatic Diseases
 US is often used first. It is moderately sensitive to
localized lesions.
 CT is used as a survey of the entire body, is easy
to compare in serial studies, and is sensitive to
disease.
 Contrast-enhanced MDCT (multidetector CT) can
be used to perform CTA.
 MR imaging is used frequently to characterize focal
lesions within the liver.
 Patient with fever and
right UOQ pain.
 CT shows a large, fluid
attenuation mass in the
posterior dome of the
liver with rim
enhancement and
irregular margins
(arrow). The most
likely diagnosis is
pyogenic abscess CT showing the
presence of gas within
the lesion (arrow)
Hydatid cyst:
 Large.
 Well defined.
 Uni/
multilocular
cystic.
 With
numerous
peripheral
daughter
cysts.
Haemangioma:
 The most common benign tumor of the
liver.
 On US, they are usually homogeneous and
hyperechoic.
 CT shows a focal lesion in the central liver
with peripheral, nodular, discontinuous
enhancement (arrow). Delayed imaging
would show centripetal accumulation (“fill
in”) of contrast. These features are
characteristic of cavernous hemangioma
(A) T2-WI shows markedly high signal intensity and well-
circumscribed margin of a cavernous hemangioma (H). (B)
Precontrast T1-WI, showing the dark signal of the lesion. (C)
arterial postcontrast T1-WI showing the peripheral nodular
“puddling” enhancement. (D) Delayed T1-WI shows the
centripetal filling in toward the center of the lesion
Metastasis:
 The liver is a common and important site.
 Most metastases are multiple, diffusely
distributed, variable in size, and solid.
Hepatocellular carcinoma:
 It is a primary malignancy of the liver.
 On imaging studies, hepatocellular
carcinoma appears as (1) a single
predominant lesion (most common form),
(2) a predominant lesion with multiple,
smaller, surrounding daughter lesions, or
(3) diffuse tumor.
 CT shows a hypervascular mass (arrow) on
arterial phase CT (A). This demonstrates
typical washout on portal venous phase
imaging (B) with an enhancing
“pseudocapsule” (arrows) of compressed
adjacent hepatic tissue. Both are typical
features of HCC.
Abdominal Trauma:
 CT is the only commonly accepted means
for analyzing abdominal trauma, particularly
of the liver.
 US may be useful if CT is not available or to
quickly identify intraperitoneal hemorrhage.
 MR has no application in studying acute
trauma
 CT of liver
laceration shows
an illdefined low-
density defect in
the liver
extending to the
capsule (arrow)
with high-
attenuation fluid
(∗) consistent
with blood
surrounding the
liver.
Bowel and mesenteric injuries
On CT, injuries of the bowel and mesentery
include:
 free air with the intraperitoneal or
retroperitoneal spaces.
 free intra-abdominal fluid.
 circumferential or eccentric bowel wall
thickening, enhancement of the bowel
wall, streaky soft-tissue infiltration of the
mesenteric fat
Perforated
viscous:
 Air under the
diaphragm in
perforated viscous .
BILIARY INFLAMMATION
 Cholelithiasis is one of the
most common abdominal
disorders and is the most
common cause of
cholecystitis.
 US is the initial mean of
diagnosis.
 On US, gallstones usually
appear as mobile, intraluminal,
echogenic foci that cast a well-
defined acoustic shadow
Findings in plain X ray:

This is a rim-like These are laminar

calcification in the wall of a calcifications. This implies
hollow viscous. In the RUQ, they are formed within a
the gallbladder is the most hollow viscous. These are
likely organ. This is called a gallstones.
“porcelain gallbladder”.
BILIARY INFLAMMATION

 On CT, gallstones appear

as dense, well-defined,
intraluminal structures.
 BILIARY INFLAMMATION

 MRCP can depict filling

defects within the biliary
tree, and congenital variants
of the biliary ducts and is
about as accurate as ERCP
in displaying a biliary “road
map.”
 The presence of a
stone within the
common bile duct
(arrowheads),
which is dilated
and inflamed
around the dense
stone. Note the
associated IHBR
dilatation (arrow).
BILIARY INFLAMMATION
 Cholecystitis is inflammation of the
gallbladder.
 It may be acute or chronic, uncomplicated
or complicated, calculous or acalculous.
 The gallbladder distends, the wall thickens
from edema, and the patient is tender to
palpation over the gallbladder.
 US is the modality of choice.
 US showing a thickened GB wall with linear,
hypoechoic fluid/edema in the wall (arrowheads).
 Numerous rounded echogenic foci with
shadowing in the neck of the GB representing
gallstones (arrow). These findings, in conjunction
with tenderness to palpation by the transducer
over the GB (sonographic Murphy’s sign), strongly
suggest acute cholecystitis.
Technique selection
PANCREATIC
INFLAMMATION OR
NEOPLASM
 Pancreatic Inflammation or
Neoplasm
 CT is often the initial means to study
pancreatic inflammation or neoplasm.
 Ultrasound may be limited.
 MR imaging may be useful to study tumors
of the pancreas.
 MRCP delineates the biliary and pancreatic
ducts and voids nearly all signal intensity
from background solid structures
Pancreatic Inflammation or
Neoplasm
 Pancreatitis, an inflammatory condition of
the pancreas.
 Acute pancreatitis can be associated with
mild to severe inflammatory edema
(edematous or interstitial pancreatitis) or
with hemorrhage (hemorrhagic or
necrotizing pancreatitis).
 The overall size of
Poorly defined soft
the pancreas (P) is
tissue planes around the
enlarged, and the
pancreas, obscuring the
tissue around the
boundary between the
pancreas is
pancreas and the
edematous with
stomach and colon
associated fluid
(arrow)
 Multiple
calcifications are
distributed
throughout the
pancreas (arrows)
and there is
enlargement of the
pancreatic duct
(arrowhead) with
atrophy of the
parenchyma
 Chronic
pancreatitis.
Pancreatic masses
 On CT, the tumor presents as a solid,
low-density, irregular mass, perhaps with
ductal dilatation, pseudocyst formation, or
both.
 Pancreatic masses
 CT shows a fluid density
lesion (arrow) in the tail
of the pancreas (P).
There is enhancement
along the rim
(arrowhead) that is not
associated with
inflammatory change in
the peripancreatic fat.
Findings are compatible
with a cystic neoplasm of
the pancreas
Peritoneal collections:
THANK YOU