5th y radiology revision

Imaging modalities in GI
• Plain X-rays (Supine, Erect, Decubitus)
• Barium studies (Ba Swallow, Meal, Follow through, Enema)
• Ultrasound Abdomen
• CT Scan/MRI Abdomen
• ERCP, Cholangiography.
• Angiography and Nuclear Medicine

Approach to abdominal x ray
• Technical Assessment.
• Projection.
• Bowel/Gas Shadows.
• Normal/Abnormal Calcifications.
• Solid Organs.
• Look at lung bases and at the skeleton.

Normal Vs Abnormal Gas
shadows
• Stomach.
• Small Bowel.
• Colon.
• Within the Lumen:
• Dilated bowel
?Obstruction
• Outside the Lumen:
• Free ?perforation
• In a cavity ?abscess

Supine plain x ray film showing
multiple dilated bowel loops.
Erect plain x ray film
showing multiple fluid
levels.
intestinal obstruction

Contrast Medium for GI
Water Soluble
• Ionic (gastrografin) Can lead
to pulmonary edema if aspirated.
• Non-Ionic ( Low Osmolar)
Relatively safer if aspirated.
• Gadolinium (MRI)
• Barium ( Non-water
soluble)
• Can cause sever peritonitis and
fibrosis in perforation or leakage.

Normal esophagus with smooth homogeneous
appearance
Esophagus

Achalasia: is a primary esophageal motility disorder
characterized by the absence of esophageal peristalsis
and impaired relaxation of the lower esophageal
sphincter (LES) in response to swallowing
Cardiac Achalasia

Cardiac Achalasia
Barium swallow showing
typical tapered narrowing of
the lower end of the
oesophagus (parrot beak
appearance).

Barium swallow showing typical tapered narrowing of the lower
end of the oesophagus (parrot beak appearance).

There is an air-fluid level (arrow).
a dilated esophagus with residual fluid. A case of achalasia.
Cardiac Achalasia

Barium swallow showing stricture in the oesophagus with
irregular outline, mucosal destruction, intraluminal filling
defects and shouldering.
Cancer
Oesophagus

•irregular stricture
•pre-stricture
dilatation with 'hold
up‘
•shouldering of the
stricture

Esophageal Varices
• Etiology: portal venous hypertension
• Classification
Uphill varices: mid to distal esophagus, portal hypertension
Downhill varices: upper or mid esophagus, SVC obstruction

Barium swallow showing worm like
filling defects along the oesophagus.

Oesophageal diverticulum
• Classification: according to their location:
• Upper oesophageal diverticula
Zenker diverticulum: actually pharyngeal but it is common practice to include it with
oesophageal diverticula
Killian-Jamieson diverticulum
• Middle oesophageal diverticula
Tractiona diverticula: are (true diverticula).
Pulsion diverticula: are usually false diverticula
• Lower oesophageal diverticula
Epiphrenic diverticula

Zenker’s
Diverticulum
Mid esophageal
Diverticulum
Epiphrenic
Diverticulum

Barium swallow showing mid oesophygeal diverticulum
on face and in profile.

Barium swallow showing
an esophageal Web

Double contrast barium
meal
Normal stomach. Double-contrast spot image of stomach with patient
supine shows distal gastric body (B) and antrum (A). Greater curvature
(white arrows) and lesser curvature (black arrows) are coated by barium.
Rugal fold on posterior wall of gastric body is depicted as tubular, slightly
undulating, radiolucent filling defect (black arrowheads) in shallow barium
pool. Dense barium pool outlines contour (white arrowheads) of gastric
fundus (F). Mucosal surface and folds in fundus are obscured by barium
pool, and antrum is devoid of rugal folds.
Duodenal cap
Stomach

Hiatus Hernia
Double contrast barium meal showing part of the stomach
pulled upward above the diaphragm

Double contrast barium meal showing part of the stomach
pulled upward above the diaphragm

• Features suggesting benign gastric ulcer:
• outpouching of ulcer crater beyond the gastric
contour (exoluminal)
• smooth rounded and deep ulcer crater
• smooth ulcer mound
• smooth gastric folds that reach the margin of ulcer
• Hampton's line
Gastric Ulcer

• Features suggesting malignant gastric
ulcer:
• does not protrude beyond the gastric contour
(endoluminal)
• irregular and shallow ulcer crater
• nodular and angular ulcer mound
• nodular gastric folds that do not reach the ulcer
margin
• Carman meniscus sign

Double-contrast spot image of gastric body with patient in left
posterior oblique position shows gastric ulcer (U) as smooth,
ovoid collection of barium (ulcer crater).

Benign lesser curvature gastric ulcer (U) as smooth, ovoid
collection of barium extending outside expected luminal
contour of gastric body (ulcer nich).

Duodenal ulcer, ovoid
collection of barium
(ulcer crater).

Barium meal showing large irregular lobulated filling defect in
the body of stomach.
Cancer Stomach

Barium meal showing
narrowing, deformity,
mucosal destruction and
shouldering (antral
carcinoma)

Barium meal showing
thickened wall encroaching
on the lumen with uniform
narrowing known as
(leather bottle stomach) or
(linitis plastica)

Barium meal folow through showing
normal small bowel appearance
Intestine

intestinal obstruction
A delayed film from a contrast
small bowel follow through
shows dilated small bowel and
a snake's head appearance in
the right inguinal region,
suggesting obstruction at this
level.

Barium meal follow
through showing multiple
small intestinal strictures
Crohn’s disease

long segment stricture of the
terminal ileum (arrows). This is
called, rather ominously, the
‘string sign of Kantor’. another
typical feature of longstanding
Crohn disease – the affected
bowel loop seems to be
separated from the normal small
bowel

Double contrast barium enema showing normal
appearance of the colon (Haustral markings)

• Bowel involved
• CD: small bowel 70-80%, only 15-20% have only colonic involvement
• UC: rectal involvement 95%, with terminal ileum only involved in
pancolitis (backwash ileitis)
• Distribution
• CD: skip lesions typical
• UC: continuous disease from rectum up
• Gender
• CD: no gender preference
• UC: male predilection
• Colonic wall
• bowel wall is thicker in CD than in UC (when colon involved)
• serosal surface smooth in UC (95%), irregular in CD (80%)
Crohn disease vs ulcerative colitis

• Bowel perianal involvement
• UC: perianal complication are not as frequently seen
• CD: common
• stranding of ischiorectal fossa/perirectal fat (73%)
• fistulas/sinus tracts (22%)
• Mesenteric creeping fat
• CD: common in chronic cases
• UD: not seen, as small bowel not involved
• Abscess formation
• CD: common, eventually seen in 15-20% of patients
• UC: uncommon
• Extraintestinal complications
• gallstones: seen in 30-50% of CD patients 2
• primary sclerosing cholangitis: more common in UC
• hepatic abscess: seen in CD
• pancreatitis: more common in CD

Double contrast barium enema of Crohn's disease
involving colon: Aphthoid lesions along sigmoid colon
Crohn’s disease

Ulcerative colitis
The whole colon, without
skips is affected by an
irregular mucosa with
loss of normal haustral
markings.

Lead pipe appearance of
colon is the classical barium
enema finding in chronic
ulcerative colitis. There is
complete loss of haustral
markings in the diseased
section of colon, and the
organ appears smooth
walled and cylindrical.

Double contrast barium enema showing multiple flask like
outpouching from the colon and filled with barium
Diverticulosis

Double contrast barium enema showing multiple filing defects of
variable sizes in the recto-sigmoid colon.
Colonic Polyposis

Cancer colon
Barium enema showing a stricture with a filling defect,
mucosal destruction and shouldering

Barium enema showing “apple core” stricture with a
filling defect, mucosal destruction and shouldering

Double contrast barium
enema showing a stricture
with a filling defect,
mucosal destruction and
shouldering (cancer
rectum).

Liver & Biliary system
NORMAL CT
ABDOMEN

Liver cirrhosis and Bulky spleen (CT)

Liver cirrhosis, bulky spleen and ascites (CT)

Axial C+ arterial phase
Axial C+ portal venous phase
Axial C+ delayed

calcified metastasis liver in NON CONTRAST CT
NB: in hepatoma
the lesions are
enhancing in the
arterial phase

ERCP showing normal appearance of the biliary
system

PTC (percutaneous trans-hepatic cholangiogram) showing
the biliary system (green arrow for Chiba needle)

T tube cholangiogram showing normal appearance
of the biliary system

Ttube cholangiogram of Calcularobstruction (stone in CBD with
dilated CBD above the detected stone)

Malignant stricture
PTC showing malignant
stricture of the common hepatic
duct with proximalbiliary
dilatation

ARTHROPATHIES
Degenerative
OA
Metabolic
Gout
Inflammatory
Rheumatoid
Spine - Big Js
Articular
Cartilage
Big toe
Intra- & peri-
articular
Hand
Synovium
Narrow J. space
Sclerosis
Osteophytes
Erosions
Swelling
Tophi
Erosions
Deformities

Gout
• Swelling
• Eccentric Erosions
• Over-hanging
• Edge

Rheumatoid
Arthritis
Deformity
Narrow joint space

Rheumatoid Arthritis
Osteoporosis
Swelling:
• fusiform
Erosions:
• Marginal, internal

Advanced changes of rheumatoid arthritis with soft tissue swelling
narrowing of the radiocarpal joint. erosions, and destruction of the
ulnar styloid. The intercarpal joints are destroyed as all of the carpal-
metacarpal joints of both hands. Note the symmetric appearance of the
disease.

Acromegaly
• Hyper-pneumatization
• Proganthism
• Enlarged pit. fossa

Terminal phalanges (spade-
like or arrow-heads)

Diabetic foot
• Bone resorption
• Disorganization
of Joints
• (Charcot’s)

Anemia
Thalasaemia
• Bone marrow
hyperplasia
• Thin cortex
• wide medulla
• Coarse trabeculae

Metastases
Multiplicity
• Osteolytic
• Sclerotic
Prostate,,, Breast
• Mixed

DD: Multiple Myeloma – Leukemia - Lymphoma

Modes of Examination of
the Urinary System
 IPUT.
 VP.
 Ascending & Micturating
cystourethrography.
 Retrograde pyelography.
 Ultrasonography.
 Isotope Renal scanning.
 Renal Angiography.
 Computerized Tomography.
 Magnetic Resonance Imaging.

Renal Hilum
1. Renal Artery
2. Renal Vein
3. Renal pelvis & ureter
4. Medullary Pyramids
5. Renal Cortex

Minor calyx
Major calyx
Renal pelvis
Papilla
IVP

• Double pelvis- single ureter

Duplex kidney and duplication of the left ureter

Right duplex kidneys and duplication of the right
ureter

Bilateral duplex kidneys and duplication of
both ureters

Crossed Ectopia
Crossed Renal
Ectopia on the
Left Kidney and
Absent Right
Kidney

IVP:
Horseshoe
Kidney
Tissue Bridge Across Midline Causes
Abnormal Orientation of Renal Axis

Cystic disease of liver and Kidneys (CT)

Primary:
NON- INFECTED URINE:
1.Calcium oxalate Calculi: usu. single, spiky,
painful bleeds. (Radio-opaque).
2.Uric acid & urate Calculi : multiple, smooth
(pure are Radio- lucent).
3.Cystine Calculi: multiple, > females, (Radio-
opaque).
Urinary tract Stones

Secondary:
ALKALINE INFECTED URINE:
Phosphate stones:
smooth, enlarge rapidly to fill the renal
calyces……..STAG-HORN calculus (Radio-
opaque).

Staghorn renal stone (PUT)
Urinary tract Stones

Dilation of Left Renal Pelvis and Calyces Above the
Obstructing Calculus

Hydronephrosis and hydroureter (US)

Bilateral Hydronephrosis (IVP)

Urinary bladder calcification (PUT)
Inflammatory Diseases

Tuberculous Renal calcification
(PUT)

Carcinoma of the Urinary
Bladder

METHODS OF INVESTIGATION
• FLOUROSCOPY
• X-RAY
• BRONCHOGRAPHY
• ULTRASOUND & ECHOCARDIOGRAPHY
• COMPUTERIZED TOMOGRAPHY (CT&HRCT)
• ANGIOGRAPHY (PULMONARY & BRONCHIAL(&
(CARDIAC CATHETERIZATION(
• ISOTOPE SCANNING
• MAGNETIC RESONANCE IMAGING (MRI)

Indications of chest X-Ray
• Respiratory symptoms(Acute & Chronic)
• Pulmonary metastasis
• Cardiovascular disease
• Pre-operative
• Pre-employments, immigrants etc.

General review
• Visible structures
1 - Trachea
2 - Hila
3 - Lungs
4 - Diaphragm
5 - Heart
6 - Aortic knuckle
7 - Ribs
8 - Scapulae
9 - Breasts
10 - Stomach
PLAIN RADIOGRAPHIC ANATOMY

• Key points
– Each hilum contains major bronchi and
pulmonary vessels
– There are also lymph nodes on each side(not
visible unless abnormal)
– The left hilum is often higher than the right
– If a hilum is out of position, ask yourself if has
been pushed or pulled
– As well as position - check the size and density
of the hila.
Hilar structures

• Lung zones
– Dividing the lungs into zones allows more careful attention to be paid
to each smaller area. If this is not done it is easy to ignore important
abnormalities.
– Note that the lower zones reach below the diaphragm. This is
because the lungs pass behind the dome of the diaphragm into the
posterior sulcus of each hemithorax.
– Normal lung markings can be seen below the well defined edges of
the diaphragm.
Lung zones

• Key points
– The pleura and pleural spaces are only visible when abnormal
– Lung markings should reach the thoracic wall
– Pleural abnormalities can be subtle and it is important to check
carefully around the edge of each lung where abnormalities are
usually seen more easily
Pleurae

• Key points
– The heart size is assessed as the cardiothoracic ratio (CTR)
– A CTR of >50% is abnormal - PA view only
– The left hemidiaphragm should be visible behind the heart
– The hemidiaphragm contours do not represent the lowest part of the
lungs
Cardiac portion

Cardiac contours
The left heart contour (red
line) consists of the left
lateral border of the Left
Ventricle (LV). The right
heart contour is the right
lateral border of the Right
Atrium (RA).
Cardiac portion

Clavicles, spinous processes and ribs

Diagnostic value of chest
radiograph
Lung parenchmal lesions
Mediastinal lesions
Plura & chest wall lesions

Pleural diseases :
*Pleural Effusion:
• Homogenous opacity obliterating the
costophrenic angle and rising to the
axilla.
• Loss of diaphragmatic and cardiac
borders (silhouette sign).

Mild left sided pleural effusion

Moderate left sided pleural effusion

Massive right sided pleural Effusion

Hemothorax: The clue to the diagnosis is the bullet was seen to lie within
the pleural space.

Massive left lung collapse
 Opaque hemi-thorax
 Mediastinal shift to the same side.

Appears as jet black translucency with absence of lung markings
Pneumothorax

Pneumothorax
marked right sided pneumothorax with lung collapse

Tension Pneumothorax
Right sided tension pneumothorax showing collapsed
lung with shift of the heart to the contralateral side.

RIGHT Hydro-pneumothorax: Air Fluid Level
Across entire hemithorax

Mesothelioma
CT Chest showing
circumferential nodular pleural
thickening encasing the right
lung
Chest PA view showing
lobulated right pleural opacities
(thickening) encasing the right
lung

-Diffuse pathology
-Focal lesions
Pulmonary lesions

• Include:
– Localized air space opacification
(consolidation/patches).
– Diffuse air space opacification (pulmonary edema
pattern)
• Unilateral
• Bilateral
– Pulmonary nodule (solitary – multiple)
– Diffuse Interstitial patterns:
• Reticulatar-nodular – reticulo-nodular infiltration
Chest patterns

Causes of consolidation:-
Transudate = Pul. Edema (cardiac – Non-
cardiac*)
Exudate = Pneumonia
Blood = (pul Infarction – Contusion – Hge)
Tumor (Alveolar cell carcinoma)

Radiological Findings: (loss of volume)
• Homogenous opacity
• Overcrowded ribs
• Look at the fissures
• Compensatory hyperinflation
COLLAPSE

 Shift of trachea to the same side and upward
traction of hilum in upper lobes
 Silhouetting in right middle lobe and left lingula
 Elevated diaphragm and downward traction of
hilum in lower lobes

Bronchopneumonia
Br.Pneumonia (irreg. – Patchy) appears as ill defined multiple
opacities of variable sizes

Pulmonary Edema
Acute intra-alveolar pulmonary edema with typical bilateral
"batwing" distribution.

Nodule
Solitary
Tumors Benign-Malignant
Infections Abscess
Hydatid
Granuloma TB
Multiple large
Metastasis
Multiple Small
TB
Sarcoidosis
Miliary metastasis

Solitary nodule
Tumors: Benign-Malignant
Infections Abscess
Hydatid
Granuloma TB

Multiple small nodules
(Miliary shadows)
Miliary TB
Sarcoidosis
Miliary metastasis

Multiple Large nodules: Metastases,
diffuse alveolar carcinoma

Canon ball metastasis, hydatid cyst

Multiple hydatid cysts or canon ball
metastases

Lucency within the lung parenchyma, with or
without irregular margins that might be surrounded
by an area of airspace consolidation or infiltrates, or
by nodular or fibrotic (reticular) densities, or both.
The walls surrounding the lucent area can be thick
or thin
Cavitary Lesion
•Coin shadow with dark center
Size > 10 mm
Wall > 3mm
+/- Air-Fluid level
+/- Crescent sign

Left Lung
Abscess
Rounded
opacity
with air-
Fluid level

AP and lateral views of lung abscess showing air
fluid level into the cavity and the small amount of
right sided pleural effusion.

The Black Lung Field
CAUSES
1- COPD (Emphysema, Chronic bronchitis
& Asthma)
2- PNEUMOTHORAX
3- OLIGEMIA PUL EMBOLISM
4- OTHERSe.g. ABCENT PECTORALIS , MASTECTOMY&
OVEREXPOSURE.

EMPHYSEMA
Exclude over-exposure
Lung Larger
* Count ribs… * Diaph. Flat
Lung Darker
* Vascular markings Decreased Attenuated
* Bulla
Heart
* Elongated & narrow * Small (Unless….?)
* Main pul. A = ….?
Barrel Chest =
* Bulging sternum * Thoracic kyphosis
* Retro-sternal space (N. < 4cm at Ao. Arch)

Hyperinflation of both lungs.
Low flat diaphragm.
Transverse ribs.
Elongated cardiac shadow.
Enlarged central pulmonary arteries with
accentuation of the peripheral
vasculature.

EMPHYSEMA
Bilateral upper zonal
emphysematous bullae
CT scan showing the
bullae more clearly.

Left apical
reticulonodular
infiltrate
pulling the left
hilum upward
TB and Fibrosis

X-ray of miliary TB
Chest radiograph shows innumerable small nodules in both lungs. The
blunting of the right costophrenic angle is suggestive of pleural effusion.

Abnormal Hilum
Larger --- Denser ---- loss of concavity
Technical
Vascular ----------- Smooth
LN -------------------- Lobulated
Bronchogenic ---- Speculated

Bilharzial pulmonary hypertension
Markedly
enlarged main
pulmonary
artery

Hodjkin disease (mediastinal
lymphoma)
Asymmetrical widening of the
mediastinum with lobulated
outline

Lymphoma
Wide superior
med.
Splay Carina
Hilar mass

Lymphoma
CT Chest showing enlarged
anterior mediastinal lymph
nodes

Bronchogenic Carcinoma
Right Bronchogenic carcinoma ---- Speculated
outline (spiky border)

Causes:
Cardiomyopathy
Multi-vavular disease
Pericardial effusion
CARDIOMEGALY

PERICARDIAL EFFUSION
Cardiomegaly and a globular heart
shape in a patient with a large
pericardial effusion.

Dextrocardia with situs inversus totalis

Infarction
Infarction in a typical
vascular territory may
suggest dissection of a
vessel.

Right tempero-parietal brain infarct
(right middle cerebral artery territory)

CT brain:
(no contrast)
Right
Intracerebral
Hge

Non contrast CT showing a left
intracerebral hematoma

Left
Intraventricular
+ intracerebral Hge

CT with contrast
>>>ring
enhancement
>>> abscess

CT with contrast
>>> heterogenous
enhancement
>>> tumour

Beaklike narrowing
in achalasia

Esophageal Cancer
Barium swallow

Zenker Diverticulum
Barium swallow

Barium swallow
Cancer esophagus

Esophageal varices
Barium swallow

Epiphrenic diverticulum
Barium swallow

Benign gastric ulcer
Barium meal

Malignant gastric ulcer
Barium meal

Sigmoid carcinoma
Barium enema

eccentric gastric ulcer (large arrow) within a
larger gastric cancer (small arrow).
Barium meal

Normal barium enema
Barium enema

Ulcerative colitis
Barium enema

Colonic diverticulosis
Barium enema

Colonic Polyposis
Barium enema

Calcified hepatic hydatid ncyst
CT abdomen without
contrast

liver cirrhosis and splenomegaly CT
CT
abdomen

ERCP
Stone with dilated biliary radicles

CT abdomen
with contrast
POLYCYSTIC
KIDNEY

CT abdomen
with contrast
HORSESHOE
KIDNEY

Massive atelactasis /collapse of right lung

Tension right pnemothorax with massive collapse of right lung and shift of the
mediastinum

RIGHT Hydro-pneumothorax: Air Fluid Level Across entire
hemithorax

5th y radiology revision

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