Imaging

Imaging

GI Surgery Unit
Faculty of Medicine
University of Alexandria

By: Mohamed Mourad University of
Alexandria
Assistant lecturer of general surgery

Different imaging modalities

University of
Alexandria

Plain chest x-ray


Plain X-ray Chest postero-anterior
view

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Alexandria

Ideal chest x-ray PA view
 Trachea

mid way between the 2 clavicles
 1/3 of the heart lies in the Rt side of the
midline
 Visible upper diaphragmatic surface from one
costophrenic angle to the other

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Alexandria

Normal plain chest x-ray PA veiw

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Alexandria

Plain chest x-ray PA veiw

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Alexandria

Plain standing x ray PA view showing
Free air under diaphragm

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Alexandria

Air under diaphragm

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Alexandria

Plain x ray PA & lateral view showing
Foreign body in thoracic esophagus

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Alexandria

Congenital diaphragmatic hernia

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Alexandria

Plain abdomen x-ray


Plain X-ray abdomen supine

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Alexandria

Plain X-ray abdomen standing

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Alexandria

Plain X-ray abdomen

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Alexandria

Plain x ray abdomen and pelvis PA
view showing Radio-opaque shadow

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Alexandria

DD radio-opaque shadow of
Rt. hypochondrium



Gall bladder stones
Renal stones (Dx Lat X-ray &
US)









Porcelain gall bladder
Calcified LN
Fracture tr. Process of
vertebra
FB
Fecolith
Calcified hydatid cyst

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Alexandria

DD: renal & gall bladder stones

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Alexandria

Radio-opaque shadow of the
abdomen x ray

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Alexandria

Chronic panreatitis

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Alexandria

Erect Plain x-ray abdomen &pelvis
PA view showing Distended bowel
loops
 Distended

Jejunal loops
–
–

Central
Valvae
conniventes

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Alexandria

Plain x-ray abdomen &pelvis PA view
showing Distended bowel loops
 Distended

loops
–
–

Ileal

Central
featureless

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Alexandria

Plain x-ray abdomen &pelvis PA view
showing Distended bowel loops
 Distended

Colon
–
–

peripheral
Colonic
hausteration

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Alexandria

Plain x-ray abdomen & pelvis
showing distended colonic loops

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Alexandria

Post operative adynamic ileus
•Supine

•Erect

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Alexandria

Plain x-ray abdomen and pelvis
showing pneumatic tire appearance

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Alexandria

Plain x ray abdomen & pelvis
showing double bubble sign

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Alexandria

Plain x-ray abdomen and pelvis
Foreign body

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Alexandria

Plain x ray abdomen showing
aeroblia

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Alexandria

Invertogram

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Alexandria

Oral Cholecystography


Steps of oral cholecystography
(OCG)
 Control

X-ray
 Ingestion of telepaque
 Another X-ray 12hrs latter
 Intake of fatty meal
 Another X-ray 2hrs latter

Remember that 85% of gallstones are
Remember that 85% of gallstones are
radiolucent
radiolucent
University of
Alexandria

Oral cholecystography (OCG)

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Alexandria

Oral cholecystography (OCG)
 Site---

(bt. 12th rib & LV1)
 Size--- (Contraction with fatty meal)
 Shape
 Filling defect
 Function (concentration & contarction)

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Alexandria

Gall stones in OCG

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Alexandria

Non visualized gall bladder in OCG
 Absent

gall bladder
 Stone in cystic duct
 Non functioning gall
bladder

University of
Alexandria

Barium swallow


Barium swallow
 Technique
 Normal
–
–

indentation

Aortic arch
Lt main bronchus

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Alexandria

Pathologies by barium swallow

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Alexandria

Achalasia of the cardia

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Alexandria

Barium swallow showing smooth
narrowing of distal end of the
oesophagus with proximal dilatation

University of
Alexandria

Barium swallow showing smooth
long narrowing of middle 1/3
oesophagus
 Corrosive
–
–
–
–
–

stricture

Single or multiple
Long segment
Smooth tapering
Usually in children
Starts at aortic arch
level

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Alexandria

Corrosive stricture

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Alexandria

Barium swallow showing Corkscrow
oesophagus

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Alexandria

Irregular filling defect mostly Cancer
oesophagus

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Alexandria

Oesophageal malignancy

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Alexandria

DD between achalasia and
malignancy
•The cardia is normally
below the diaphragm

•In X-ray 1, the
oesophagus is
interrupted above
the diaphragm
•In X-ray 2, the
cardia below the
diaphragm is
closed with “bird
beak-like” shape

University of
Alexandria

serpiginous filling defects in the
oesophagus Oesophageal
varices

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Alexandria

Barium swallow with outpouch of the
barium--Oesophageal diverticula

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Alexandria

Epiphrenic and Zenker’s diverticulum

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Alexandria

Oesophageal web

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Alexandria

Barium meal


Barium meal

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Alexandria

Barium meal

 Large

volume low
density
 Distension of
stomach by
volume

 Small

volume high
density+ effervescent
 Distension of stomach
by buscopan
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Alexandria

Barium meal (Single & Double)

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Alexandria

Barium meal
 1,

Gastric antrum
 2, pyloric canal
 3, duodenal cap
 4, duodenal loop

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Alexandria

Pathological findings in barium meal

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Alexandria

Hiatal hernia

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Alexandria

Barium meal in trendlenberg position
showing Sliding hiatal hernia

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Alexandria

Barium meal in trendlenberg position
showing paraoesophageal hiatal hernia

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Alexandria

Barium meal showing
paraoesophageal hiatal hernia

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Alexandria

Barrett’s oesophagus

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Alexandria

Benign gastric ulcer

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Alexandria

 On

lesser curvature
 Convergence of
mucosal folds
 Out pouch

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Alexandria

Barium meal showing ulcer nich at the middle of
lesser curvature with mucosal convergence

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Alexandria

Hour glass deformity

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Alexandria

Normal duodenal cap and DU

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Alexandria

2 kissing duodenal ulcers

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Alexandria

Trifoliate deformity of DU

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Alexandria

Gastric tumors

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Alexandria

Malignant gastric ulcer

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Alexandria

Malignant gastric ulcer
 Any

site of stomach mainly antrum and
greater curvature
 Ulcer dose not protrude to the outside
 Mucosal folds obliterate before the edges of
the ulcer

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Alexandria

Lintis platica

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Alexandria

Lintis plastica

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Alexandria

Pyloric filling defect of malignant
origin

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Alexandria

Pre-pyloric tumor

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Alexandria

Duodenal diverticulum

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Alexandria

Barium meal showing dilated stomach reaching
pelvis with mottled dye without passage of dye
to dudenum (Gastric outlet obstruction)

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Alexandria

Barium meal showing Soap dish
appearance

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Alexandria

Congenital hypertrophic pyloric
stenosis

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Alexandria

GOO by compression from outside

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Alexandria

GOO by pseudopancreatic cyst

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Alexandria

Volvulus of the stomach
•Organoaxial volvulus

•Mesenteroaxial volvulus

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Alexandria

Organo-axial volvulus

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Alexandria

Duodenal atresia

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Alexandria

Barium follow through


Barium follow through

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Alexandria

Stricture of small intestine
•Chron’s
•Lymphoma
•TB
•Radiation

University of
Alexandria

Chron’s stricture
 Commonly

at terminal

ileum
 Multiple, rigid, irregular
stricture (string sign of
Kantor)
 Skip lesions
 Cobble stones
 Polyps
 Fistula

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Alexandria

Barium enema


Barium enema

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Alexandria

Normal barium enema filling phase

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Alexandria

Pathological findings in barium enema

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Alexandria

Transverse colon filling defect

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Alexandria

Transverse colon filling defect
(colonic malignancy)

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Alexandria

Cancer ascending colon

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Alexandria

Barium enema showing arrest of the
dye at the level of rectosegmoid
junction due obstruction of the lumen

University of
Alexandria

Diverticulosis

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Alexandria

Chron’s disease
 Commonly
 Multiple,
 Skip

at terminal ileum

rigid, irregular

lesions

 Cobble

stones

 Polyps
 Fistula
 Loss

of hausterations
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Alexandria

Ulcerative colitis
 Rectosegmoid
 Loss

of hausteration
 Polyps
 No skip lesion
 Narrow colon (lead pipe)

University of
Alexandria

Ischemic colitis
 segmental

narrowing
of the entire
transverse colon.
 Within the narrowed
segment, there are
multiple nodular
indentations, many of
which have the
appearance of
thumbprinting

University of
Alexandria

DD of colonic stricture
 Chron’s
 TB
 Cancer
 Diverticulitis
 Ischemic

colitis

caecum
iliocecal
segmoid
segmoid
splenic flexure

University of
Alexandria

Hirschsprung disease
 Stenotic

segment
 Dilated rectum
 Transitional zone
(funnel)
 Delayed
evacuation

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Alexandria

Rounded filling defect (polyps)

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Alexandria

Rectosegmoid polyps

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Alexandria

Barium enema showing hundreds of
filling defects of the entire colon (FAP)

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Alexandria

Intussusception

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Alexandria

Barium reduction of intussusception
•Head of intussusception
is at hepatic flexure

•Partial reduction

•Free flow of contrast into
distal small bowel indicates
complete reduction

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Alexandria

Biliary imaging


Types

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Alexandria

Normal PTC

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Alexandria

CBD stone-PTC

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Alexandria

CBD stone-PTC


One or more intraluminal
defects (round, faceted or
lobulated) which produce
varying degrees of biliary
obstruction are seen.



Occasionally stones are
noted as small multiple
free-floating defects in a
non-dilated duct.
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Alexandria

CBD stricture PTC

Transhepatic
cholangiogram showing a
stricture of the common
hepatic duct

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Alexandria

ERCP


Normal ERCP

•Common bile
duct
•Gall bladder
•Common hepatic
duct
•Rt. & Lt. hepatic
ducts

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Alexandria

CBD stone-ERCP

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Alexandria

Multiple intrahepatic & extrahepatic
stones

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Alexandria

Bile duct carcinoma-ERCP
A

short segment
constricting lesion
with irregular
margins was noted
at the bifurcation of
the common hepatic
duct (Klatskin
tumour)
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Alexandria

Stents insertion-ERCP

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Alexandria

Cholangiogram


Normal T-tube cholangiogram

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Alexandria

CBD stone, T-Tube

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Alexandria

Transcystic IO cholangiogram

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Alexandria

Radiological pattern reflecting the
cause of biliary obstruction
 Choledocholithiasis

(biliary duct stones)
–
–

–

One or more intraluminal
defects (round, faceted or lobulated)
Occasionally stones are noted
as small multiple free-floating
defects in a non-dilated duct.
Sometimes impacted with
crescent sign.
University of
Alexandria

 Pancreatic

carcinoma
–

–

Complete or almost
complete obstruction of
the mid or distal common
duct, usually over a long
segment (3-4 cm) of the
distal duct
(intrapancreatic portion)
is seen.
A "rat-tail" configuration is
the typical appearance

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Alexandria

 Cholangiocarcinom

a

–

–

The narrowing may
occur at any level and
typically presents as a
segmental stenosis.
When the lesion is
located at the
bifurcation, it is referred
to as a Klatskin tumor

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Alexandria



Benign stricture
–

–

There is a short segmental
circumferential stricture in
the mid-common duct in a
patient with a previous
cholecystectomy.
Most benign strictures are
secondary to ductal injury
during cholecystectomy.
(iatrogenic)
University of
Alexandria

 Ampullary

carcinoma
–
–

Focal obstruction of very
distal CBD is noted.
A smooth constriction or
an irregular polypoid mass
growing into distal CBD
may be seen.

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Alexandria

 Ascariasis
–

Worms are seen
extending through the
common bile duct and
major hepatic ducts

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Alexandria

MRCP


Normal MRCP

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Alexandria

CBD stones-MRCP

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Alexandria

Klatskin tumor-MRCP

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Alexandria

Biliary injury-MRCP

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Alexandria

Liver imaging


Hydatid liver cyst
 Fluid

attenuation

 No

peripheral
enhancement

 Daughter
 Well

cysts

defined

 Rounded

or oval
University of
Alexandria

Imaging

Thank You


Imaging

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