Lecture 5.

Gastro-intestinal
radiology
Orenburg state medical university
Department of radiology, radiotherapy and oncology
HOD, prof. A.G. Shekhtman
Ass. M.L. Kalinina
Acute abdominal series
View Look For
Supine abdomen Overall bowel gas pattern,
calcifications, masses
Prone abdomen Gas in the rectosigmoid colon
Upright abdomen Free air, air–fluid levels in the
bowel

Upright chest Free air, pneumonia, pleural

effusions
What to look for
1. Overall gas pattern
2. Presence of extraluminal air
3. Abnormal abdominal
calcifications.
4. Any soft tissue masses
Normal bowel gas pattern
Distention is normal
Dilatation is abnormal
• Stomach almost always contains air
• Small bowel –usually contains a small
amount of air in about two or three loops
of nondilated small bowel.
• The normal diameter is <2,5 cm
• Large bowel – almost always contains air
in the rectum or sigmoid colon.
Normal gas pattern
Normal colonic distention
Normal fluid levels
• Stomach
• almost always an air–fluid level in the stomach on an
upright abdominal image
• Small bowel
• two or three air–fluid levels in the small bowel may be
seen normally on an upright or decubitus view of the
abdomen.
• Large bowel
• no or very few air–fluid levels in the colon
Normal distribution of gas
and fluid in the abdomen
Organ Normally Normally has
contains gas air-fluid level
Stomach Yes Yes
Small bowel yes, 2-3 loops Yes
Large bowel Yes, especially no
rectosigmoid
colon
Normal small bowel

• Central position in
the abdomen
• Valvulae conniventes
- mucosal folds that
cross the full width of
the bowel
(arrowheads)
Normal large bowel
• Peripheral position in
the abdomen (the
transverse and
sigmoid colon occupy
very variable
positions)
• Haustra
(arrowheads)
• Contains faeces
Soft tissues
There are two fundamental ways of recognizing the presence,
and estimating the size, of soft tissue masses or organs:

• The first is by direct visualization of the edges of the

structure, which can only occur if the structure is surrounded
by something with a density different from that of soft tissue,
such as fat or free air.

• The second is to recognize indirect evidence of the mass or

enlarged visceral organ by recognizing pathologic
displacement of air-filled loops of bowel.
Normal soft tissues
Calcification and artifact
Key points
• Added densities may be due to artifact or
calcified soft tissue
• Calcification of soft tissues is not always clinically
significant
• Differentiating pathological from inconsequential
calcification is not always straightforward
Calcification and artefact
Abnormal bowel gas pattern
KEY QUESTIONS:
• Are there dilated loops of small and/or large bowel?
• On plain films, is there air in the rectum or sigmoid?
• On CT, is there a transition point?

• FUNCTIONAL ILEUS
• Localized ileus (sentinel loops)
• Generalized adynamic ileus
• MECHANICAL OBSTRUCTION
• Small bowel obstruction (SBO)
• Large bowel obstruction (LBO)
Abnormal bowel gas pattern
Air in Air in Small Air in Large
Rectum (R) Bowel Bowel
or Sigmoid (amount od
(S) dilated loops)
Normal Yes Yes—1-2 loops R and/or S
Localized Yes 2-3 dilated loops R and/or S
ileus
Generalize Yes Multiple Yes—dilated
d ileus
SBO No Multiple No
LBO No None Yes—dilated
Functional ileus:
localized sentinel loops
Key imaging features
• On conventional
radiographs, there are
one or two persistently
dilated loops of small
bowel.
• There are frequently air–
fluid levels seen in
sentinel loops.
• There is usually gas in
the rectum or sigmoid
Functional ileus:
generalized adynamic ileus
Key imaging features
• The entire bowel is
usually air-containing
and dilated
• Many long air–fluid
levels in the bowel.
• Presence of gas in the
rectum or sigmoid.
• There is no transition
point identified on CT of
the abdomen.
Mechanical obstruction:
small bowel obstruction
Key imaging features
• Multiple dilated loops
of small bowel
proximal to the point
of the obstruction
(>2.5 cm).
• Step-ladder
appearance (numerous
air–fluid levels)
• There might be little or
no gas in the colon,
especially in the
rectum.
Mechanical obstruction:
large bowel obstruction
Key imaging features
• The colon is dilated to the
point of obstruction.
• Dilatation of the caecum
>9cm, and >6cm for the rest
of the colon is considered
abnormal
• The small bowel is not
dilated (unless the
ileocecal valve becomes
incompetent).
• Rectum contains little or no
air.
• No or very few air–fluid
levels in the large bowel.
Volvulus. Sigmoid and Caecal
Sigmoid volvulus. Caecal volvulus
Coffee bean sign Embryo sign
Extraluminal air
The four most common locations of
extraluminal air are:
• Intraperitoneal (pneumoperitoneum)
• Retroperitoneal air
• Air in the bowel wall (pneumatosis
intestinalis)
• Air in the biliary system (pneumobilia)
Pneumoperitoneum
3 major signs:
• Air beneath the
diaphragm
• Visualization of both
sides of the bowel
wall
• Visualization of the
falciform ligament
Pneumobilia
Radiographic features
• Tubelike, branching
lucencies in the right
upper quadrant
overlying the liver
• Tubular structures are
central in location and
few in number compared
with portal venous air,
which is peripheral in
location and fills
innumerable vessels
• Gas in the lumen of the
gallbladder
Pneumatosis
• Linear radiolucency
paralleling the contour of
air in the adjacent bowel
lumen

• Mottled appearance that

resembles air mixed with
fecal material

• Globular, cystlike
collections of air that
parallel the contour of
the bowel
Ascites
• There is generalised
hazy density of the
entire abdomen
• A loop of gas filled
bowel lies centrally in
the abdomen
Fluoroscopy
• Barium sulfate (swallow, meal, enema)
• A single-contrast (also called full-column) – only
barium is used as the contrast agent;
• Double contrast (sometimes called air contrast) –
both thicker barium and air are used;
• Spot films and overhead films
• Lesions :
• Intraluminal
• Intramural
• extrinsic
Important signs
• Filling defect
A lesion, usually of soft tissue density, that protrudes into the
lumen and displaces the intraluminal contrast (e.g., a polyp is a
filling defect).
• Ulcer
A persistent collection of contrast that projects outward from the
contrast-filled lumen and originates either through a break in the
mucosal lining (as in gastric ulcer) or in a GI mass (as in an
ulcerating malignancy).
• Diverticulum
A persistent collection of contrast that projects outward from the
contrast-filled lumen of the GI tract like an ulcer; unlike an ulcer, the
mucosa of a diverticulum is intact; false diverticula represent
outpouchings of mucosa and submucosa through the muscularis.
Esophagus
• Single- and/or
double-contrast
examinations of the
esophagus
• Video
esophagography
(video swallowing
function)
• Fluoroscopic
observation of the
esophagus
Esophagus. Tertiary waves
• Disordered and
nonpropulsive
contractions of the
esophagus.
• corkscrew esophagus
 Esophagus. Achalasia
Plain radiograph (CXR)
• convex opacity overlapping the right
mediastinum.
• air-fluid level
• small or absent gastric bubble
• anterior displacement and bowing of the
trachea on the lateral view
Fluoroscopy with barium swallow
• bird beak sign
• esophageal dilatation
• tram track appearance
• incomplete lower esophageal sphincter
relaxation
• uncoordinated, non-propulsive contractions
• pooling or stasis of barium in the esophagus
• failure of normal peristalsis to clear the
esophagus of barium
Esophagus. Carcinoma
Forms:
• an annular constricting lesion;
• polypoid mass;
• a superficial, infiltrating lesion or ulceration;
• irregularity of the wall.
Esophagus. Diverticula
Locations:
• the neck – Zenker diverticulum.
• around the carina – traction diverticula);
• just above the diaphragm – epiphrenic diverticula
Hiatal hernia and
gastroesophageal reflux
The radiologic findings
• a bulbous area of the distal esophagus containing oral contrast at the
level of the diaphragm,
• extension of multiple gastric folds above the diaphragm;
• visualization of a thin, circumferential filling defect in the distal
esophagus called a Schatzki ring
Normal stomach and small
bowel
Gastric ulcer
• Collection of barium that protrudes beyond the expected
contour of the normal body of the stomach
• Present on multiple views – persistence
• Ulcer collar – a mound of edematous tissue that surrounds the
ulcer .
• Gastric folds radiate to the ulcer margin
• Central barium collection
Gastric cancer
• Gastric carcinoma is the most common cancer in the world
after lung cancer and is a major cause of mortality and
morbidity
• Adenocarcinoma is the most common type (95%)
• 2 types:
• Type 1 adenocarcinomas are intestinal tumors and have well-
formed glandular structures.
• Type 2 adenocarcinoma is a diffuse type with poorly cohesive
cells, which tend to infiltrate the gastric wall.
• Patients with atrophic gastritis are in risk group
Early gastric cancer
Advanced gastric carcinoma
• polypoid cancer can be lobulated or fungating
• lesion on a dependent or posterior wall; filling defect in
barium pool
• lesion on non-dependent or anterior wall; etched in white by
a thin layer of barium trapped between edge of mass and
adjacent mucosa
• ulcerated carcinoma (penetrating cancer): 70% of all gastric
cancers
Benign vs malignant ulcer
Feature Benign Malignant
Position Exoluminal Endoluminal
Ulcer crater smooth rounded irregular and
and deep shallow
Ulcer mound smooth nodular and angular
Gastric folds smooth , reach the Nodular, do not
margin of the ulcer reach the margin of
the ulcer
Hampton’s line yes no
Carman’s no yes
meniscus sign
Chron’s disease
Imaging findings
• narrowing, irregularity, and ulceration of the terminal ileum
frequently with proximal small bowel dilatation;
• separation of the affected loop(s) from the surrounding loops
of small bowel (proud loop);
• the string sign(narrowing of the terminal ileum into a near
slitlike opening by spasm and fibrosis;
• Fistulae
Barium enema
Colonic polyps
• Polyps may be sessile (attach directly to the wall)
or pedunculated (attach to the wall by a stalk)
• Polyps can be recognized as persistent filling
defects in the colon.
Colonic carcinoma
The imaging findings
• the presence of a
persistent, large,
polypoid filling defect;
• annular constriction of
the colonic lumen,
producing an apple-
core lesion;
• frank or
microperforation
• large bowel
obstruction
Colitis
“Thumbprinting” Lead pipe colon
 THANK YOU FOR
YOUR ATTENTION!
QUIZZ 1
Answer:
• Normal
QUIZZ 2
Answer:
Calcified gallstone
QUIZZ 3
Answer:
LBO
QUIZZ 4
Answer:
• Colonic cancer –
apple core sign
(red circle)
• Colonic diverticuli
(black arrows)
QUIZZ 5
Answer:
Narrowing and
irregularity with
hold-up of contrast
noted in the mid
thoracic esophagus
(red circle).

Esophageal cancer
Wish all of you great success in
your future career!