Dept.

of Radiology
Medical Faculty Muhammadiyah
University

General Objective
To provide basic
understanding about the role
of radiological imaging in
diagnosing
gastroenterohepatologic
diseases

Specific objectives
Imaging modalities and

techniques/examination
procedures
Radiological appearances of
some GIT and hepatobiliary
diseases

Organs scope
Plain

Abdomen
Esophagus-rectum
Liver
Biliary tract
Pancreas

In general
Plain abdominal radiography
Conventional radiography with

contrast media
Imaging (US, CT-Scan, MRI,

Nuclear medicine)

Plain abdominal
radiography
Commonly used in emergency cases such
as ; ileus (dynamic or adynamic), peritonitis,
free-air/fluid, blunt or penetrating trauma,etc
Usually needed 3 standard positions :
1. Erect
2. Supine
3. LLD ( left lateral decubitus)

Large bowel obstruction

Less commonly than small bowel

obstruction
Three main causes : - colon
carcionoma
- Volvulus
- Diverticulitis

Small bowel obstruction

Radiological signs
Bowel distended filled by gas++
Lack gas in the distal part
Air fluid level (step ladder appearance)
Valvula conniventes appears as herring bone

(herring bone appearance)

Pneumatosis intestinalis

( Gas within bowel wall )

Necrotizing enterocolitis ( NEC)

Peritonitis
Bowel wall thickening
Properitoneal fat line

disappear/ obliterate
Paralytic ileus sign

Adynamic or paralytic
ileus
Bowel distended until distal

part
Air fluid levels (+) , longer
Herringbone appearance(-)

Radiography with
contrast

Barium Sulphate (BaSO4)

suspension
Iodine

Indication : - Disturbances of swallowing

- Tumors of the base of the tongue
& epiglottis
Salivary glands :
Consist of : - Parotic glands
- Submandibular glands
Indications : Stones; inflamation; neoplasm
Technique : - Plain Foto
- Sialography
- CT
- MRI

Sialography :
Duct orifice. is located & intubated by a blunt
needle/abbocath
0,5 1,5 ml contrast medium (water soluble/lipiodol)
injected slowly & then taking a series pictures
Give a few drops of lemon juice make an after lemon
film 10 later to evaluate the remaining contrast
Abnormalities :
Chronic obstructive Sialectasis
- stone
- strictures
Chronic non-obstructive Sialectasis (chronic inflamation)
Tumours (mostly mixed salivary type)

Esophagus :
It should be visualized with contrast media
(Barium Sulfat) Esophagography
Indications : - Dysphagia
- Dyspepsia
- Haematemesis/melena
- Congenital anomalies ?
Technique of Examination :
The patient is asked to swallow a thick
Barium
Sulphate (1:1) or Iodine ( for baby) and
followed by
fluoroscopy & taking radiography

B. Abnormalities :

Congenital malformation
- Esophageal atresia
- Short esophagus with a thoracic
stomach
(Brachy-esophagus)
- Duplication
Traumatic Disorders rupture
Abnormalities in density foreign bodies
Abnormalities in Size (length & diameter)
Abnormalities in architecture

 Radiography positions : - AP
- Right Anterior
Oblique
projection (RAO)
- Left Anterior Oblique
projection (LAO)
- Spot Film (optional)
Radiological Signs :
A. Normal Indentations : - Knob aorta
- Left main bronchus
- Left atrium
- Hiatus hernia

Esophageal atresia

Esophageal varices
Caused by portal

hypertension, commonly
seen in cirrhosis hepatis
cobble stone appearance

Esophageal stricture
Narrowing and irregularity
due to corrosive materials
(corrosive stricture)

Tumours :
- Benign

: Filling defect with smooth

border
Forked stream appearance
(Fluoroscopy)
- Malignant : Filling defect with irregular
border
Spasticity

ACHALASIA
Aganglionic of the distal part of

esophagus
Distal smooth narrowing with
dilatation of the proximal
segmen--- mouse tail app.

MOUSE TAIL APPEARANCE

GASTRODUODENOGRAPHY
(= Maag Duodenum/MD Foto)
Is a radiographic evaluation of the
stomach & duodenum by introducing
contrast media inside [Barium sulfat (+)
& air/gas (-)
Indication : - Dyspepsia
- Epigastric pain
- Vomiting
- Haematemesis/melaena

Procedure Of Examination
1. Preparation : fasting 4-6 hours
2. The patient swallows contrast Barium

Sulfat (& air) followed by fluoroscopy

and taking radiography in various
position
3. Usually in Supine, Prone, Prone
oblique, Erect. Spot-Film Compression
(recommended)

Normal Anatomic Radiography

Radiographic Abnormalities of
Gastroduodenal Disease.
It can be classified as changes in :
Position
Size (redundancy, enrlargement/widening,

narrowing/shrinkage)
Contour
Rugae abnormalities
Filling defect
Function

Left lateral
erect film of the
stomach

Fig. 28-14.

Pyloric stenosis
= Infantile Hypertrophic Pyloric Stenosis

DIVERTICLE
- Protrution of mucosa and
submucosal outward
- Additional shadow

Gastritis
Mucosal atrophy
Mucosal hypertrophy-

hypersecretion
three level density

Peptic ulcer
Mostly seen in pyloric antrum and duodenal bulbus

Primary Signs :
- En face (frontal view)barium spot with halo (active ulcer)

and star sign ( inactive)

- En profile (lateral view)additional shadow , globular
shape (active ulcer), conus (inactive)

Secondary signs
Contralateral/opposite spastic

insicura
Hypersecretion
Bulb deformity

TUMOR
BENIGN
Filling defect with smooth border

Maligna
Types :
1. Early gastric cancer
Limited in mucosa/submucosa
mimicking
ulcer
2. Advance gastric cancer
Filling defect irregular border
- Annular ( infiltrating type )
- Exophytic ( fungating type )
- Linitis plastica ( schirrus type)
- Ulcer type, filling defect + ulcer

DUODENUM
Congenital :

Stenosis post bulbar

duodenal atresia
Two bubbles app.

SMALL INTESTINE (JEJENUM & ILEUM)

Normal size: - 20 feets (length)
- 2,5 cm (jejenum); 1,75 cm
(ileum)
in diameter
Indications:

Anemia (unclear origin)

Persistent diarrhoe
Abdominal pain
Palpable mass
Excessive protein loss
Malabsorbtion

 Contraindication:

Obstruction signs
Perforation
Paralytic ileus
Peritonitis
Technique of Examination

1. Plain abdominal radiography

2. Follow Through
Patient is asked to swallow 200-300 cc Barium
sulfat (1:2-3 water),followed by taking pictures
30-60 minutes interval until contrast seen in
caecum

Abnormalities

Crohns Disease = Regional

ileitis
Adhesion
Fistula

COLON
Indication : Haematochesia
Persistent diarrhea
Abdominal mass
Obstructive symptoms
Congenital abnormalities
Contraindication : Ileus (Paralytic)
Suspect Bowel Perforation
Peritonitis

Technique of Examination : Barium enema

(colon inloop)
Mostly DoubleContrast method
Preparation is the most important to remove
faecal material from the colon
Colon inloop : - Using a thin Barium sulfat
(1:3-6) aprox. 2 L
- Contrast should fill colon entirely
(rectum-caecum)
- Picture taken in many positions/
views.

COLON
A.Kongenital
1. Atresia Ani (Imperforate anus) , Foto polos
abdomen terbalik (Inverogram) untuk
melihat udara paling distal.
- Letak rendah
- Letak tinggi
2. Hirschsprungs disease ( megacolon
congenitum ) colon distal menyempit,
bagian proximal lebar dapat dilihat
dengan memasukkan barium (barium
enema).

Normal Radiographic
Appereance
Abnormalities
Carcinoma of Colon
3 types : Fungating type/exopitic
Polypoid type
Annular type/infiltrating

Fungating type :
- usually medullary Ca.
- Sites: Caecum, Ascending Colon,
Rectum
- Complication: Bleeding, fistula
Polypoid type :
- Sites: usually Descending Colon
- Complications: Intussusception

Annular type :
- Sites: Sigmoid, Descending Colon,
flexures
- Complication: Fistula, obstruction
Pathology : - 50 75% adeno Ca.
- 20% fibro Ca.
- 10% mucoid adeno Ca.
Metastasis : Liver or regional nodes
Radiographically :
Filling defect with
Obstruction signs

Obstruction
Obstruction to the flow of Barium can be caused
by :

Spasm

Annular Carcinoma

Intusussception

Volvulus

Diverticulitis
Displacement of the Colon :
causes :
- Enlarge Liver
- large
abdominal mass
- Enlarged Spleen
- Pelvic mass
or tumor
- Stomach mass
of Spine

Dilatation/Distension :
- Idiopathic symptomatic megacolon (older age)
- Hirschsprungs disease (megacolon congenital)
Disease of childhood, mostly males
Abscent of ganglion cells in the mesenteric
plexus in the narrowing segment (mostly
sigmoid colon, 40%)
Marked dilatation above the area of
aganglionosis.
Radiographically :
- Plain abdominal films veriable degrees of
distension of GIT above the obstruction

- Colon in loop :
Narrowing along the site of aganglionosis
Dilatation above the narrowing, might be
associated
with irregularity/sawtoothing/ulcerative
Colitis
Narrowing of the Colonic Lumen :
Congenital stricture or atresia Ani
varies from an imperforate anal membrane to
complete
atresia of the entire anus
Ulcerative Colitis
- Loss of haustra
- Contracted,shortened & small calibre
- Saw-toothing/ulceration
- Stringiness/String sign

Radiographically :
Technique of examination for atresia
ani:
Inverted or Wangesteen position
Knee-chest position
Aim : to identify the lowest end of air in
colorectal

Letak
Rendah
Letak
Tinggi

Intussusception = Invagination
A proximal segment of bowel
(intussusceptum) into lumen of a distal
segment (intussuscepiens)
Location : Ileoileal > ileocolic > colocolic
Radigraphic sign : Coiled spring or
cupping
sign
proximal bowel dilatation
- absence of gas in distal
segment

US findings :
-Target sign, doughnut sign or bulls
eye sign (transverse scan )
- pseudokidney sign ( longitudinal scan)

Inflammation :
- Ulcerative colitis
- Crohns Disease

Diverticle

HEPATOBILIER & PANCREAS

Imaging modalities :

- USG
: Ultrasonografi / Ultrasound
- CT scan : Computerized Tomography
Scanning
- MRI
: Magnetic Resonance Imaging
- MRCP
: MRI for
Cholangiopancreatography.
- PTC(D) : Percutaneus Transhepatic
Cholangiography ( Drainage )
- T-Tube Cholangiography, Durante operatif ,
Post operatif
- Nuclear Medicine

Gallstones/cholelithiasis
- Soliter / multiple
- Echogenic/hyperechoic structure
dengan
acoustic
shadowing

Acute Cholecystitis
* Gallbladder wall thickening
> 3 mm
* Sludge

CIRRHOSIS HEPATIS
- Liver atrophy
- Increasing echogenecity,
fibrotic.
- Irregular of the surface
- Portal hypertention
- Splenomegaly
- Ascites.

HEPATOCELLULAR CARCINOMA/HCC
HEPATOMA
USG : Iso hipo or hiperechoic
mass
Ill-defined
TUMOR METASTASIS
Noduler bull-eye, usually multiple,
Well defined

Liver abscess
Hypoechoic mass
Irregular and thicken wall

Liver cyst
Free-echoic mass, well
defined,
Solitary or multiple

Biliary obstruction
Causes :
- Stone
- Tumor intra/extraluminer.
- Strictur cholangitis, etc