Radiology of the Abdomen

1
BRUCE TOVEE LECTURES

• Radiology of the Abdomen
• April 4 2005
• University of Toronto
• Nasir Jaffer
• Associate Professor
• Mount Sinai Hospital University Health Network

2
Plain Films of the Abdomen Normal Views
UPRIGHT DIAPHGRAMATIC
SUPINE ABDOMEN
UPRIGHT ABDOMEN
This view shows diaphragm Assessing for free
air air/fluid levels
The entire abdomen is imaged
To assess air/fluid levels
3
Plain Films of the Abdomen Normal Views
SUPINE ABDOMEN
LEFT LATERAL DECUBITUS
A left lateral decubitus view ( left side down)
is done depending on patients clinical state
4
Air over liver
Left lateral decubitus
5
Air over liver (black)
6
An Approach to Abdominal Plain Films

• ABDOMINAL FILM REVIEW CHECK LIST
• Technique
• Gas pattern
• Intraluminal
• Extraluminal
• Intramural
• Retroperitoneal
• Intraperitoneal (free air)
• Organ (portal venous, bile duct, gallbladder,
  urinary bladder, kidneys etc)
• Intraluminal Air
• Air - fluid levels (colonic or small bowel)
• Bowel wall diameter (dilated, normal)
• Bowel thickness

7
Role of Plain film

• Acute Abdomen
• Bowel Perforation
• Toxic megacolon
• Bowel Ischemia
• Large bowel
• Small bowel
• Small Bowel Obstruction
• High grade
• Low grade
• Large Bowel Obstruction
• Volvulus
• Carcinoma

• Chronic Symptoms
• Constipation
• Calcifications
• Gallstones
• Renal stones
• Urinary bladder stones
• Usless in
• GI Bleed
• Chronic anemia
• Vague GI symptoms

8
RADIOGRAPHIC SIGNS OF ILEUS V/S BOWEL OBSTRUCTION

• Bowel obstruction
• Differential Air fluid levels
• Dilated bowel
• No air beyond obstructed segment
• String of pearls sign
• (only with small bowel)
• Step ladder pattern of bowel
• Gasless abdomen

• Ileus
• Air throughout the GI tract
• Normal calibre bowel
• Air fluid levels at same level (no pressure
  differential)

9
Bowel Obstruction
4cm
Differential air-fluid levels (in the same loop)
Dilated bowel
10
String of Pearls Sign
Left Lateral decubitus
11
Large Bowel Obstruction
Splenic flexure
Haustra
Ascending colon
Transverse colon
7 cm
upright
supine
Air/fluid levels
Dilated colon (with haustra)
(Picture frame location of large bowel)
12
Imaging of Bowel Obstruction

• - Rarely cause of bowel obstruction
• found on plain film
• Need further imaging
• CT best choice of imaging

Stone
Gallstone ileus
13

Role of CT in Bowel Obstruction

• Un-resolving bowel obstruction
• Suspected closed loop SBO
• History of neoplasm (serosal met)
• Plain film Gasless abdomen
• Distinguishing post op. ileus v/s obstruction
• Suspect S.B Ischemia (ileus on plain film)
• Virgin Abdomen with SBO

14
LARGE BOWEL OBSTRUCTION
15
CT SCAN OF LARGE BOWEL OBSTRUCTION
Cecum
Sigmoid tumor
16
CONTRAST STUDIES FOR LARGE BOWEL OBSTRUCTION
17
HYPAQUE ENEMA

• Apple core lesion
• Recto-sigmoid
• Carcinoma
• Contrast studies
• rarely used

18
IMAGING THE SOLID ORGANS

• Contrast studies of GI tract
• Imaging solid organs (U/S, CT etc)

19
CONTRAST STUDIES OF GI TRACT
1 Barium - Upper GI series - Small bowel
studies (SBFT Enteroclysis) - Barium enema 2
Water soluble contrast - ERCP/PTC - Hypaque
enema Mostly for mucosal and mural disease
20
BARIUM SWALLOW
Patients cine esophagogram is shown. ?
Patient drinks barium ? Also takes gas pills
movie
21
DOUBLE CONTRAST UPPER GI SERIES
? Patient drinks barium ? Also takes gas pills
fundus
cap
antrum
body
22
SMALL BOWEL CONTRAST EXAMS
Tube
Tube
Small bowel
cecum
CROHNS ILEITIS
Small Bowel enema (Tube)
Small bowel follow through (drinking)
23
DOUBLE CONTRAST BARIUM ENEMA

• TECHNIQUE
• Patient has bowel cleansing
• Rectal tube placed
• Barium and air or Carbon dioxide instilled
• Multiple images taken.
• INDICATIONS
• Diverticulosis
• Anemia
• Diarrhoea
• Incomplete colonoscopy
• Inflammatory bowel disease
• Constipation.

Normal colon
24
IMAGING OF SOLID ORGANS

• Imaging Studies
• Plain films Not used
• Ultrasound Solid/hollow viscus
• CT Solid/hollow viscus
• MRI Solid organs bowel
• ERCP/PTC Bile/pancreatic ducts

• SOLID ORGANS
• Liver
• Spleen
• Gallbladder
• Pancreas
• Bile ducts
• Pancreatic ducts
• Genito-urinary system
• Kidneys,Urinary bladder
• Prostate/seminal vesicles
• Uterus/ovaries/fallopian tubes

25
ULTRASOUND OF THE SOLID ORGANS
Anterior
Anterior
RT
LT
Pancreas
GB
IVC
CBD
SMA
Portal vein
Aorta
Gallbladder
Pancreas
26
IMAGING IN WOMEN
Uterus
Bladder
Fetus
Transvaginal ultrasound
Abdominal ultrasound
Ultrasound the first imaging study of choice for
any symptoms
27
Sophisticated Imaging of GI Tract
ULTRASOUND OF THE PELVIS (UTERUS)
Bladder
Feet
Head
Uterus
CERVIX
IUD
28
CT SCAN OF ABDOMEN
REMEMBER PATIENTS WITH ALLERGY TO
CONTRAST Special Allergy Protocol must be
given - Steroids Antihistamine -
RADIOLOGIST MUST BE INFORMED BEFORE CT
29
CT TECHNIQUE PRINCIPLES
1 Patient preparation - IV started - Oral
contrast given (barium or water soluble) -
Rectal contrast (colonic lesions) - IV contrast
given in the room during CT 2 Types of CT -
Plain CT (e.g renal colic CT, Hemorrhage) -
Portal phase Contrast CT (most CTs) -
Arterio-venous CT (liver, pancreas bile duct
tumors)
30
INDICATIONS FOR BIPHASIC CT STUDIES
1 Known vascular lesions - hemangiomas -
hepatocellular carcinoma - vascular mets
(breast, melanoma, GIST) 2 Distinguish benign
v/s malignant lesions - Focal nodular
hyperplasia - Adenoma - Hepatocellular
carcinoma 3 Anatomical map for surgeon -
Liver transplant - Liver resection 4
Demonstrate bleeding sites (vascular lesions in
GI tract) - small bowel stromal tumors -
active bleeding sites
31
ARTERIO-VENOUS CT OF LIVER HEMANGIOMA
Arterial phase Portal
venous phase Delayed phase
Hemangioma characteristics - Nodular
peripheral arterial enhancement - Filling in of
lesion in portal delayed phases
32
IMAGING THE BILE DUCT

• Ultrasound
• CT
• Contrast studies ( PTC ERCP)
• MRI Cholangiography
• Intra-operative cholangiography

33
Percutaneous Transhepatic Cholangiogram (PTC)
Dye injected through needle to visualize bile
ducts.
Needle
34
ENDOSCOPIC CHOLANGIOGRAM

• Gatroenterologist performs study
• Indications
• Jaundice
• Bile duct stones
• Pancreatic disease
• Interventional (stent)

Primary Sclerosing Cholangitis
Endoscope
35
Nuclear Medicine Scan

• 1 RBC Bleeding scan
• Upper or lower GI bleed
• 2 Gallium scan
• Infection or lymphoma
• 3 Meckels Scan
• 4 Liver Spleen Scan
• Hemangioma

36
MECKELS SCAN Tc 99 Scan
Stomach

• Technetium 99 injected
• Positive scan
• Gastric mucosa in Meckels

uptake
bladder
37
Case 11
GALLIUM SCAN

• Gallium injected
• Scan done 24-48 hrs later

Intense uptake of gallium LUQ
Increased uptake at tail of pancreas Differential
diagnosis Abscess Lymphoma
Anterior Posterior
38
Case Scenarios
39
Case
40
ABDOMEN CASE 2 CLINICAL HISTORY Young
25-year-old female with sudden onset of abdominal
pain followed by severe right shoulder tip pain.
She has had amenorrohea for 11 weeks. PHYSICAL
EXAMINATION She has deep supra pubic pain and
has a BP of 89/50 QUESTION What is your
clinical diagnosis
41
CLINICAL DIFFERENTIAL DIAGNOSIS (Acute symptoms)
? Ovarian pathology - Torsion - Ruptured
hemorrhagic/cyst - Tubo-ovarian abscess -
Ectopic pregnancy ? Gastrointestinal -
Appendicitis - Diverticulitis (right or
left)
42

• QUESTION
• What is the best imaging test for this young
  women?
• Plain film of the abdomen
• Ultrasound
• CT
• MRI

43
TRANSVAGINAL ULTRASOUND
Anterior
UTERUS
Left
Right
?
44
ECTOPIC PREGNANCY
Uterus
Rt Ovary
Fetus in uterus
Fetus
Normal Intrauterine pregnancy

• Ultrasound Findings
• Uterus is empty
• There is a fetus in the pelvis ectopic
  pregnancy

45
PATHOPHYSIOLOGY OF ECTOPIC PREGNANCY
46
COMMON SITES OF ECTOPIC IMPLANTATION OF FETUS
47
RADIOLOGY PEARL
1 Ultrasound first imaging of choice in women of
child bearing age 2 Ectopic pregnancy - an
emergency
48
Case
49
Plain film

• Young patient with sudden onset of
• abdominal pain and has guarding

50
UPRIGHT
SUPINE
51
FREE INTRAPERITONEAL AIR
Air under diaphragm
Small bowel
Cecum
Riglers sign
UPRIGHT
SUPINE
52
Case
53
Plain film

• Middle aged patient presents with nausea
• vomiting and abdominal distension

54
(No Transcript)
55
ETIOLOGY OF BOWEL OBSTRUCTION
ON PLAIN FILMS

• Adhesion (post operative)
• Hernias (external hernias)
• Tumor (primary/secondary)
• Inflammations (Crohns, Appendicitis,
  Diverticulitis)
• Foreign body (gallstone)
• Congenital (malrotation, atresia, annular
  pancreas etc))
• Volvulus (large bowel)
• Vascular compression (SMA syndrome)
• Miscellaneous

56
GALLSTONE ILEUS
57
Gall Stone Obstruction (Ileus)
Triad Air in Biliary ducts - 33 Calcified
gallstone - 33 Small bowel Obstruction -
100 Sites of obstruction - Duodenum/ampulla -
Ligament of Treitz - Terminal ileum - Meckels
diverticulum - Sigmoid colon - Adhesions
58
Case
59
Plain film

• Case 2
• Elderly patient from Nursing Home
• presents with abdominal distension and
• constipation

60
Rectal Tube
61
SIGMOID VOLVULUS
The COFFEE BEAN sign
62
Case
63
Plain film

• Case 3
• CLINICAL HISTORY
• Young patient with right flank pain radiating
  down the groin
• P/E Normal abdominal findings
• Q Your clinical diagnosis?
• Q What is your next investigation

64
What X-Ray study would you order?

• Plain films
• Contrast Studies (barium, water soluble hypaque
  etc)
• CT Scan
• Ultrasound
• MRI
• Or I would CALL
• Gastroenterologist (Scope etc)
• Interventional radiology
• SURGEON

65
PLAIN CT SCAN OF ABDOMEN
NON-CONTRAST CT FOR RENAL COLIC
Technique 1 No preparation 2 CT scan from
top of Kidney to symphysis pubis
Avi file click mouse
66
NON-CONTRAST CT FOR RENAL COLIC
UPPER CT SLICE
LOWER CT SLICE
Dilated Renal pelvis
Calculus in ureter
67

• INDICATIONS FOR PLAIN CT OF THE ABDOMEN
• Contrast allergy
• Renal failure (unless on dialysis)
• Renal colic
• Intra-abdominal hemorrhage
• Post heparinization
• Bleeding from abdominal aneurysm
• Trauma
• Post cardiac angiography (from femoral artery
  cannulation)

68
Case
69
Plain film

• Case 4
• Young patient presents with bloody
• diarrhoea, fever and acute abdominal pain.
• What is your clinical diagnosis?

70
What X-Ray study would you order?

• Plain films
• Contrast Studies (barium, water soluble hypaque
  etc)
• CT Scan
• Ultrasound
• MRI
• Or I would CALL
• Gastroenterologist (Scope etc)
• Interventional radiology
• SURGEON

71
Left decubitus Abdomen film
12 cm
Transverse colon
72
Diagnosis Toxic Mega colon

• Radiographic findings
• Dilated transverse colon (gt 7cm)
• Loss of the colonic folds (haustral folds)
• Free intraperitoneal air

73
Diagnostic criteria for toxic megacolon

• Total or segmental non obstructive colonic
  dilatation
• With systemic clinical toxicity

• Ref Gastroenterology Clinics Volume 32 Number
  4 December 2003 Review article Inflammatory
  bowel disease emergencies
• Onki Cheung, MD Miguel D. Regueiro, MD

74
TOXIC COLON WITH THUMB PRINTING
MUCOSAL EDEMA
75
PSEUDOMEMBRANOUS COLITIS
Thickened colonic wall and Mucosal enhancement
Normal CT of transverse colon
76
RADIOLOGY PEARL

• Toxic mega colon requires clinical and
  radiographic findings for diagnosis
• Plain films best imaging
• To assess calibre of bowel lumen
• Repeat films help when change in clinical status
• CT helps with assessing extent and complications
  of disease (perforation, bowel infarction,
  abscess

77
Case
78

• ABDOMEN CASE 6
• HISTORY
• Elderly patient with long history of atrial
  fibrillation.
• Presents to Emergency Department with sudden
  onset of abdominal pain.
• PHYSICAL EXAMINATION
• Diffuse tenderness throughout the abdomen
• RADIOLOGIC INVESTIGATIONS
• Plain films were done which were normal
• Then a CT scan of the abdomen were done (shown)

79
PATIENTS CT SCAN
CT SCAN OF NORMAL SMALL BOWEL
80
Radiographic signs of bowel ischemia

• Bowel wall thickening
• Pneumatosis
• Portal venous air
• Mesenteric vessel engorgement
• Thrombus or embolus in artery or vein
• Ascites

81
CT SCAN OF SMALL BOWEL PNEUMATOSIS AND PORTAL
VENOUS AIR
Intramural air in small bowel
Portal venous air
82
COLONIC ISCHEMIA Thumb printing
Transverse colon
83
1 Conventional Angiogram Invasive
(puncture femoral artery) Using catheter
2 CT Angiogram Contrast injected IV
Computer generated images
SMA Angiogram
Angio of SMA with embolus (arrow)
84
CT Angiography
Celiac Axis
Aorta
Superior Mesenteric artery
A.P View
Lateral view
85
RADIOLOGY PEARL
1 CT scan the ONLY definitive imaging study for
bowel ischemia 2 CT angiography (CTA) is the
technique used - Intravenous contrast
used - Images then reconstructed using special
software
CTA
86
Case
87
ABDOMEN CASE 4 CLINICAL HISTORY 56 Year old
patient with left lower quadrant pain, fever and
diarrhea. PHYSICAL EXAMINATION He has left
lower quadrant tenderness. The blood work
revealed leuckocytosis. IMAGING DONE A CT
Scan of the abdomen was done. Images are shown
below
88
CT SCAN OF THE PELVIS
Sigmoid colon
89
CT SCAN OF THE PELVIS
Sigmoid colon
ABSCESS AROUND THE SIGMOD COLON (arrow)
THICKENED SIGMOID COLON
90
ACUTE INFLAMMATORY CONDITIONS IN THE ABDOMEN
EXAMPLES 1 Gastro-intestinal tract -
appendicitis, diverticulitis, acute
cholecystitis, pancreatitis 2 Genito-urinary -
hydrosalpinx, pyelo-nephritis etc
91
CT SCAN OF APPENDICITIS
Imaging of appendicitis 1 Ultrasound -
especially females - reduce radiation 2 CT -
Accurate - Can drain abscess
92
ACUTE CHOLECYSTITIS (on CT)
Thickened gallbladder wall (4mm)
Pericholecystic fluid (arrow)
Ultrasound is most commonly used for acute
cholecystitis
93
GENITOURINARY INFLAMMATORY DISEASE e.g.
Hydrosalpinx Investigations - Ultrasound
imaging of choice - CT done for percutaneous
drainage
94
BILATERAL HYDROSALPINX
Normal fallopian tube
Uterus
OVARY
95
RADIOLOGY PEARL
1 CT Ultrasound imaging of choice for
inflammatory disease of GI Tract 2 Also same
imaging used for radiological treatment (abscess
drainage)
96
Case
97
Sophisticated Imaging of GI Tract
Case 1 Clinical history Patient with long
standing history of gastrointestinal reflux
disease (GERD) Now presents with dysphgia and
anemia Q What is your diagnosis? Q What
investigations would you do?
98
Endoscopy
Tumor
Gastric fundus
Endoscope
99
What is the next step?

• A) Treat
• Surgery
• Radiotherapy/chemotherapy
• B) Further define extent of lesion
• How long is tumor
• Stage cancer

100
The next step

• B) Further define extent of lesion
• How long is tumour
• Barium study
• Stage cancer
• CT scan

101
DOUBLE CONTRAST ESOPHAGEAL STUDY
102
STAGING ESOPHAGEAL CANCER
1 Contiguous spread (to structures in the
vicinity) 2 Lymphatic 3 Hematogenous 4
Distant
103
Esophagus with barium
IVC
Stomach
Lymph node
Esophagus with barium
Aorta
104
HEMATOGENOUS METASTASIS
Liver Metastasis
E- G junction carcinoma
Carcinoma of distal esophagus with hepatic mets
(CT sensitivity 70-80) Via the portal venous
system
105
Other causes of dysphagia

• Cervical esophagus
• Thoracic esophagus
• Gastro-esophageal junction

106
ESOPHAGEAL WEBS
Etiology Caustic ingestion during childhood
107
SCHATZKIS RING
Etiology Secondary to GERD Definition of
Schatzki ring - Columnar epithelium below -
Squamous epithelium above
Barium swallow
108
RADIOLOGY PEARL
1 Contrast studies of GI tract only assesses
mucosal disease 2 Other imaging needed to
better define lesion stage cancers
109
Case
110
Sophisticated Imaging of GI Tract
Case 2 Clinical history Young patient with 5
month history of right lower quadrant crampy
pain diarrhoea, and weight loss. Now has
pneumaturia Q What is your diagnosis.
111
What would you do next

• Plain films
• Contrast Studies (barium, water soluble hypaque
  etc)
• CT Scan
• Ultrasound
• MRI
• Or I would CALL
• Gastroenterologist (Scope etc)
• Interventional radiology
• SURGEON

112
SMALL BOWEL ENEMA STUDY
Small bowel
Cecum
Fistula
Bladder
113
(No Transcript)
114
Nodular-ulcerative form
115
Featureless Type
116
Stenosing Type The string sign
Transverse colon
117
Radiology Pearl

• Contrast studies are useful to assess small
  bowel disease
• Other Imaging studies include CT

118
Case
119
Sophisticated Imaging of GI Tract
Case 3 Clinical history Elderly patient with
melena and weakness. Hgb 90 Q Was admitted
for investigation Q What is your differential
diagnosis?
120
What X-Ray study would you order?

• Plain films
• Contrast Studies (barium, water soluble hypaque
  etc)
• CT Scan
• Ultrasound
• MRI
• Or I would CALL
• Gastroenterologist (Scope etc)
• Interventional radiology
• SURGEON

121
Investigations done

• Normal gastroscopy
• Normal colonoscopy
• with 20 cm of terminal ileum visualized
• What would you do next?

122
INVESTIGATION FOR GI BLEEDING
123
Tc99 Sulfur Colloid Bleeding Scan

Increased radioactivity Left upper quadrant
476077821
124
SMALL BOWEL FOLLOW THROUGH STUDY
Patient had a GI stromal tumor Of proximal jejunum
Tumor
125
Imaging of GI Bleeding

• Small bowel the source
• Imaging tests
• Barium studies (SBFT, SBE)
• M2A Pill
• CT
• Conventional CT
• CT Enteroclysis

126
X-Ray INVESTIGATION OF GI BLEEDING
1 Small Bowel Barium studies - SBFT - lt 5
lesions detected - SBE lt 10 lesions
detected 2 Bleeding sans (RBC labelled Tc
Pertechnetate) - Rate of bleeding detected
about 1-2ml/min - Longer intravascular half
life can scan later - Not accurate in
localising site of bleeding - In case series
85 lesions missed1 3 Angiography -
Invasive - Can detect 0.5mls per min
bleeding - Brisk bleeding detection of lesion
50-72 - Slow (or stopped) bleeding 25-50
lesions detected. 1 Surgery 1991110799-804
127
SMALL BOWEL ENEMA
SMALL BOWEL ENEMA
8F Entriflex Tube
128
Meckels Diverticulum Small Bowel Follow Through
Meckels Diverticulum ? Heterotopic tissue,
present in 50 of cases ? Mucosa is more
likely to be gastric (80), ? Pancreatic,
jejunal and colonic mucosa also found.
Stomach
Meckels
Small bowel
129
MECKELS DIVERTICULUM Nuclear Medicine Tc 99 Scan
Stomach

• Rate of bleeding about 1-2ml/min
• Longer intravascular half life
• Not accurate in localising site
• of bleeding
• - In case series 85 lesions missed

uptake
bladder
130
CT Enteroclysis

• CT ENTEROCLYSIS
• Technique
• Small intubated with 8F catheter
• 2 litres of fluid instilled
• CT scan of abdomen

131
Angiography

• Superior mesenteric angiography
• Invasive
• Can detect 0.5mls per min bleeding
• Brisk bleeding
• detection of lesion 50-72
• Slow (or stopped) bleeding
• 25-50 lesions detected

STROMAL TUMOR Bilobed hypervascular lesion
132
M2A Pill - Small bowel Luminal Imaging
Patient monitoring device
Courtesy GIVEN IMAGIING
133
Small bowel Images with M2A Pill
Normal
Ulcer
Courtesy GIVEN IMAGIING
134
Radiology Pearl

• GI Bleed are investigated with multiple of
  imaging studies
• Contrast studies
• CT
• Normal
• CT enteroclysis (infusing oral contrast)
• Nuclear Bleeding scans
• Angiography (rarely used now)

135
Case
136
Sophisticated Imaging of GI Tract
Case 4 Clinical history Elderly patient with
weight loss, back pain Physical Exam Overtly
jaundiced Q What is the next investigation
137
Investigation of Jaundiced patient

• Depends on the type of jaundice
• Pre-hepatic
• Hepatic
• Post hepatic
• B) Investigation of jaundice require most of the
  following modalities
• - Ultrasound first imaging study
• - CT scan
• - MRCP
• - Endoscopic retrograde cholangiopancreatogram
  (ERCP)
• - Percutaneous cholangiogram

138
PATIENT HAD AN ULTRASOUND OF THE LIVER
Liver
Portal vein
139
PATIENT HAD AN ULTRASOUND OF THE LIVER
Liver
Portal vein
Dilated bile duct
140
Q What should be the next investigation
141
Investigation of Jaundiced patient
B) Investigation of jaundice require most of the
following modalities - Ultrasound first imaging
study - CT scan - MRCP - Endoscopic
retrograde cholangiopancreatogram (ERCP) -
Percutaneous cholangiogram (PTC)
142
EXAMPLES OF IMAGING STUDIES
143
ULTRASOUND OF THE BILE DUCT AND PANCREAS
Anterior
Anterior
RT
LT
Pancreas
GB
IVC
CBD
SMA
Portal vein
Aorta
Pancreas
Bile duct Gallbladder
ULTRASOUND THE FIRST IMAGING OF CHOICE !
144
CT SCAN OF PANCREATIC CANCER

• CT done for diagnosis staging tumor
• Lesion size
• Location (head, body or tail)
• Invasion
• Local (GI tract)
• Vascular (esp venous)
• Metastasis (liver, bile duct etc)

145
CT SCAN OF PANCREATIC CANCER
Bile duct
Pancreatic mass
Dilated pancreatic duct
CT shows dilated bile ducts and mass in head of
pancreas
146
ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAM
CBD
ERCP ? Double Duct sign - Dilated CBD -
Obstructed Pancreatic duct ? Diagnosis
Pancreatic ca
Pancreatic duct
147
PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAM
Right duct
Narrowing at ductal confluence
CBD
Cholangiocarcinoma of Bile duct
148
Case 4
MRI of bile ducts
CHD
CBD
Duodenum
No radiation used
149
Case 4
RADIOLOGY PEARL
1 Investigation of jaundice require most of the
following modalities - Ultrasound first imaging
study - CT scan - MRCP - Endoscopic
retrograde cholangiopancreatogram (ERCP) -
Percutaneous cholangiogram
150
Case
151
Sophisticated Imaging of GI Tract
Case 5 Clinical history Young patient with
night sweats fever. On physical exam enlarged
right neck lymph nodes Q What is your
clinical diagnosis? Q What is the next best
investigation? - Plain Films - Ultrasound -
CT - MRI - Nuclear Gallium scan
152
(No Transcript)
153
aorta
aorta
Pt CT
aorta
aorta
ivc
ivc
aorta
aorta
NORMAL CT
PATIENTS CT
Normal CT
Normal CT
154
GALLIUM SCAN
liver
liver
Gallium avid area
Normal Study
Patients Study
155

• Diagnosis Non-Hodgkins Lymphoma

156
Lymphoma of small bowel
Radiographic findings Thick small bowel
folds Bowel loop separation (mesenteric mass)
001 056 886
Pt. with nocturnal fever, and weight loss.
157
LYMPHOMA OF STOMACH
UGI shows thick walled stomach CT
scan shows enlarged Celiac lymph nodes
158
Radiology Pearl

• Lymphoma in the abdomen can affect the GI tract,
  lymph nodes,
• liver, spleen and even the kidneys
• Imaging studies for diagnosing and staging
  lymphoma
• CT scan (best imaging test)
• Contrast studies for the GI tract
• Nuclear medicine (gallium scan) to assess
  activity of disease

159
Case
160
Sophisticated Imaging of GI Tract
Case 6 Clinical history Elderly patient has
had constipation and pencil thin stools for 6
months What is your diagnosis?
161

• What is the next investigation ?
• Refer to Gastroenterologist (gastroscopy,
  colonoscopy)
• Call Radiologist (Barium enema, UGI)
• Refer to surgeon (total colectomy)
• Send patient home

162

• Colonoscopy was done
• Patient could not tolerate the study.
• What would you do next?

163
Barium enema was done
Apple Core lesion
Normal barium enema
Barium enema
164

• Diagnosis Carcinoma of colon

165
CT Colonography Requires Bowel cleansing Two
sets of CT- Prone Supine
166
Uses of Virtual Colonoscopy
1 Only for detecting polyps or cancers 2
May reduce waiting times for colonoscopy - if
normal then patient can wait 3 Incomplete
colonoscopy on high risk ( for colon cancer)
167
A 8mm polyp seen in Right Colon (on Axial CT
image )
168
RADIOLOGIST EXAMINES THE WHOLE COLON
Movie
169
CT Scope can go through narrowed bowel
CANCER
170
Case
171
History Elderly patient seen at Urology
Clinic with microscopic hematuria.
QUESTIONS List ALL radiological studies used
in investigation of hematuria
172
INVESTIGATING HEMATURIA Answer Radiological
studies used in investigation of hematuria a)
Ultrasound b) Intravenous Pyelogram (done
rarely) c) Retrograde pyelogram d) CT
scan - Non contrast (for stones) - Contrast
(for tumors)
173

• Question 2
• List clinical situations when intravenous
  contrast is contraindicated
• Previous contrast allergy
• Pheochromocytoma
• Malignant hyperthermia
• Diabetes
• Multiple myeloma
• Renal failure

174
A Retrograde Pyelogram
A retrograde Pyelogram was done by the
patients urologist SHOWN BELOW (Technique
Using cystoscopy, a catheter is passed into
the ureter and radiopaque contrast injected
and an image is taken)
175
A Retrograde Pyelogram
A retrograde Pyelogram was done by the
patients urologist SHOWN BELOW (Technique
Using cystoscopy, a catheter is passed into
the ureter and radiopaque contrast injected
and an image is taken)
Filling defect in renal pelvis
176
DIAGNOSIS Transitional cell carcinoma of the
ureter
177

• OTHER CAUSES OF HEMATURIA
• Renal cell carcinoma
• Bladder tumours
• Infections (e.g. Tuberculosis)
• Miscellaneous
• A-V malformation
• vascular mets

178
RENAL CELL CARCINOMA
venous
ARTERIAL
VENOUS
A large vascular lesion of mid pole left kidney
with invasion of Gerotas fascia
179
RADIOLOGY PEARL
For HEMATURIA multiple imaging studies done -
Ultrasound of kidney, Bladder, prostate -
Renal CT - Intravenous pyelogram -
Retrograde Pyelogram
180
Case
181
Abdomen Case 7 Clinical History Elderly
patient with long standing history of hepatitis
C. Had an ultrasound which showed liver
lesion. A CT scan with intravenous contrast was
done (shown below) Question 1 What is the
finding?
182
Normal CT
Patients CT
183
Differential diagnosis of liver lesions 1
Vascular - hepatocellular carcinoma (HCC) -
metastasis (GIST), breast, carcinoid, renal cell
ca) - arterio-venous malformation - focal
nodular hyperplasia, adenoma 2 Avascular -
metastasis (GI tract malignancy) - benign
cysts - infections (abscess, TB, hydatid etc)
184
Case
185
History Alcoholic patient had a CT scan
Patients CT
CT of liver on normal patient
186
Case
187
History Young patient with hypertension
188
Polycystic Disease

• Liver, renal, pancreas and adrenals have cysts

CAROTID ANGIOGRAM
Aneurysm
189
Sophisticated Imaging of GI Tract
Pancreatic cases
190
Normal CT Anatomy of Pancreas
SMV
CBD
Pancreatic duct
191
Case
192

• History
• Young patient with severe epigastric pain.
• Had been drinking for 24 hours
• Q Your clinical diagnosis?
• Q Next investigation?

193
Patients CT
Normal CT
433 529 898
194
CT SCAN FOR PANCREATITIS

• To confirm diagnosis
• To check course of disease
• To assess complications
• Pseudocyst
• Abscess
• Bleeding (pseudo aneurysm)
• Infarction (necrosis)

195

• Abdomen Case 8
• Clinical History
• Elderly patient with hypertension presents to
  Emergency Department
• with acute abdominal pain and in shock
  (hypotension).
• Physical Examination
• Revealed tender distended abdomen and a palpable
  pulsatile periumbical mass
• BP 50/40

196
QUESTIONS Q 1 What is your Clinical
Diagnosis? Q 2 Of these imaging studies which
ones have a high diagnostic yield? - 3 views
of the Abdomen - Ultrasound of the
abdomen - CT scan - Angiography of the
abdominal aorta - MRI
197
Patients CT
Normal CT
198
Patients CT
Normal CT
Aorta
199
CT FINDINGS Large retroperitoneal hematoma
with a large abdominal aneurysm DIAGNOSIS Blee
ding aortic aneurysm SURGICAL EMERGENCY
200
RADIOLOGY PEARL
1 For Acute hemorrhage CT is the only imaging
done - Plain CT for intra abdominal bleed
- CTA for aneurysmal bleed
201
LAST Case !!!!!!
202
Challenge Case
History Young 24 yr old had lung transplant for
bronchiectasis.
PANCREAS
Normal CT
Patients CT
203
Diagnosis Absent pancreas Cystic fibrosis
204
Sophisticated Imaging of GI Tract
End of Seminar
Thank you for your patience and good luck!