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IMAGING MODALITIES Improve reading skill of abdominal imaging • PLAIN FILM • ULTRASONOGRAPHY • BARIUM EXAMINATION ผศ นพ สิทธิพงศ ศรีสัจจากุล BODY IMAGING • CT Department of Radiology, SirirajHospital, • MRI MahidolUniversity • PET

@ King ChulalongkornMemorial Hospital, 25 november12

PLAIN FILM

• ACUTE ABDOMINAL SERIES -CXR upright PLAIN FILM -Plain abdomen supine and upright

Density in Plain Film Plain Abdomen: Upright View

3 Liver 4

2 3 1 1 = air Properitoneal 2 = fat fat line 4 Abdominal 3 = soft tissue wall 5 4 = bone Small bowel loops 5 = metallic

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Plain Abdomen: Supine View Plain Abdomen vs Plain KUB

Transverse Stomach colon

Descending colon

Supine Plain KUB

PLAIN ABDOMEN How to read plain abdomen 1 Abdominal wall and properitonealfat line

2 Distance between bowel wall and abdominal Peripheral to central approach or vice versa wall

3 Gas distribution in GI tract ( stomach, small bowel and large bowel)

4 Soft tissue density in abdomen such as solid organs, fluid-filled bowel loops

PLAIN ABDOMEN

5 Bony structures

6 Detection of abnormalities -Abnormal gas -free air , bowel dilatation, pneumatosis -Abnormal mass -intraperitoneumor retroperitoneum -Organomegaly -Abnormal calcification -Foreign bodies

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ABNORMAL PLAIN FILM

CXR upright

moderate to marked pneumoperitoneum Plain abdomen upright

triangular sign

• ICU admission • Sick patient • No upright film

liver diaphragm

ascites Triangular sign

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• Cupola sign • Cupola sign • Free air outline • Free air outline visceral structures visceral structures • Air outline lateral umbilical ligament

Pneumoperitoneum Pneumoperitoneum

Left lateral decubitus film!!!! helpful

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SBO vs LBO • Position of bowels – Small bowel: central – Large bowel: periphery • Folds: – Small bowel: valvulae conniventes – Large bowel: haustra • Diameter – Small bowel: 3cm Small bowel obstruction – Large bowel: 6cm, cecum 9 cm

Ileus vs Gut Obstruction Paralytic Ileus

• Proportion of prox. and distal bowels • Upright view: air fluid level • Thickness of bowel wall • Bowel sound • Follow up film

String of beads

• String of pearl sign • curvi-linear arrangement of air bubbles • valued sign of obstruction (as opposed to ileus) • small bubbles of air trapped in the valvulae of the fluid filled small bowel.

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Slit/Stretch Sign -small amounts of air caught in the valvulaeof fluid- filled bowel -highly suggestive of small bowel obstruction.

Coil spring sign Gasless small bowel obstruction

• small bowel loops are filled with normal small bowel content

-dilated air-filled small bowel -most noticeable in the jejunum where the valvulae conniventesare closely spaced.

Imaging features of SBO SMALL BOWEL OBSTRUCTION

• Air filled Coil spring sign • PLAIN FILM

• Partial fluid-filled Multiple air fluid levels Detectable radiographic sign but no identifiable cause • Nearly complete fluid –filled String of beads Slit/strecthsign

• Complete fluid -filled Gasless SBO

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Colonic volvulus FAQ

• 11 % of all volvulus • Deficient peritoneal fixation of cecum The Gas in the Rectum • Younger patients than sigmoid volvulus Ignore or Important? • 30-60 years • 2 types( axial and loop type) • Location of caput cecum • DDX -Cecal bascule Gas in the rectum is widely considered a useful indicator to exclude bowel obstruction

• This sign is unreliable.

• Bowel is often partially obstructed, allowing the • A lack of gas in the rectum is worthy of passage of bowel contents past the level of the consideration partial obstruction. • Gas in the rectum does not exclude bowel obstruction • More importantly, the large bowel produces its own gas through fermentation processes • A collapsed large bowel is a more reliable sign of bowel obstruction • Even in cases of complete obstruction, gas in the rectum may persist for several days

• Introduce via PR exam

Abnormal Calcifications Gallstones

• Gallstone • KUB stone • Calcified organs -Pancreas, nodes • Calcified old granuloma -liver , spleen • Calcified mass

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Calcified Pancreas Calcified Nodes

Calcified Splenic Granuloma Calcified Uterine Fibroid

Foreign Body: opaque

Foreign body

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Coin in Esophagus vs Trachea

Ultrasonography

Esophagus Trachea

Ultrasound

• PROS – No radiation, no contrast – Real time and portable – Cheap and available – Multiplanar – Good for DDx cyst / mass – Good for vascular evaluation ( doppler ultrasound)

• CONS – Not suitable in obesity – Not suitable for bowel evaluation – Operator dependent

Normal Liver Normal Ultrasound

1 2 3

PV/CD Pancreas Spleen

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Normal Kidneys Terminology 1 2 3 • Echogenicity -high : soft tissue , fat, hemorrhage, calcification -intermediate : soft tissue -low: cyst or fluid content RL/RK RK LK

Liver Mass Ascites

LV

Bile Duct Dilatation shadowing

Posterior acoustic Posterior acoustic shadow enhancement

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shadowing shadowing

Dirty shadowing Dirty shadowing

• Posterior acoustic enhancement cystic lesion ( simple cyst or cystic tumor) • Posterior acoustic shadow calcified lesion ( GS, renal stone) • Dirty shadowing air or gas ( aerobilia, emphysematous cholecystitis or pyelonephritis) • No shadowing mass or soft tissue fat Acute calculous cholecystitis

Acute acalculousemphysematous cholecystitis RLQ pain

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Acute appendicitis

• Dilated appendix • Diameter morethan 6 mm • Appendicolith • Periappendiceal abscess

• Pro:

– See mucosal / intraluminal lesion – Real time Barium examination – Dynamic study [anatomy and movement (peristalsis)]

• Cons: – Radiation – Contrast use: barium or water soluble contrast – Need experience of performer

Barium Swallowing: Spot Films

– Barium swallowing or Esophagography – Upper GI study/series (UGIS) or GI single meal (GISM) – GI follow through (GIFT) or Long GI study or Small bowel series valleculae – Barium Enema • Single and double contrast pyriform Valleculae sinuses – Others: pyriform • Loopography sinuses

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Esophagus AP view Esophagus oblique view

Barium Swallowing: Overhead Film

Diaphragm

EG junction

Esophagus AP view Esophagus oblique view Oblique view AP view

Mucosal Detail UGIS: Spot Views

GI Follow Through GI Follow Through

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Normal BE Single vs Double Contrast A. Ileocecal valve H B. Terminal ileum F C. Appendix D. Cecum E. Ascending G I colon E F. Hepatic flexure G. Transverse colon D J C H. Splenic flexure I. Descending A B colon K J. Sigmoid colon K. Rectum Spot Film Overhead Film

Barium Enema: Overhead Barium Enema: Spot

Pattern Approach IMPORTANCE !! • Outpouching lesion -Ulcer, diverticulum • • Questionable small or large bowel Intrinsic filling defect obstruction -Polyp or malignancy – Start with barium enema to rule out large • Extrinsic pressure effect bowel obstruction • Narrowing of lumen -Stenosis, circumferential mass • Fold thickening -regular , irregular : short or long segment • Leakage of contrast (extravasation) and fistula

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Intrinsic vs Extrinsic Intrinsic vs Extrinsic • DDx when fully distended bowel • Angle – Intrinsic : acute angle – Extrinsic: obtuse angle • Mucosa – Intrinsic: irregular or smooth – Extrinsic: smooth • Mass effect – Intrinsic: no – Extrinsic: yes

Narrowing of Lumen Stenosis vs Annular Lesion

• Stenosis (A) – Smooth or irregular – Tapering • Circumferential mass (annular lesion) (B) – Irregular – Abrupt change A B

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Two conditions !!!!!

• classic films • detectable cause

aerobilia portal venous gas

Sigmoid volvulus

Coffee bean sign

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Conclusion

• Plain film -normal density Case examples -imaging approach • Ultrasound -terminology -shadowing • Barium examination -modalities -single and double contrast

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