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Chapter 15: Gastrointestinal
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XRAY ABDOMEN WITH MULTIPLE AIR FLUID LEVELS AFL
73
Figure 5: This is a digital skiagram of abdomen AP view with lower part of chest and upper part of pelvis taken in erect posture showing multiple air
ierential Diagnosis
D
Include all causes of intestinal obstruction. Some common causes are:
In wall of intestine In lumen of intestine Outside the wall of intestine
Inammatory bowel disease Bezoars Postoperative adhesions
Fibrous stricture Gall stones (rare) Hernia
Neoplastic lesions Worms Intussusception
ey Points
K
Dierence between jejunal and ileal loops radiologically
Location Central abdomen Central abdomen
Valvulae conniventes Present (Indicated by white lines in gas lled gut) Absent (Characterless)
Colonic gas shadows:
¾ Situated peripherally
¾ Haustrations present in walls
Normal AFL (More than this may suggest obstruction):
¾ Adults – < 3
¾ Infants – 2–5
Normally AFL present at:
¾ Fundus of stomach
¾ Duodenal cap
¾ Caecum/Terminal ileum
uid levels in abdomen in central location suggestive of small bowel obstruction
Foreign body Internal volvulus
Jejunal Loops Ileal Loops
74
Section 3: X-rays
SIGMOID VOLVULUS
Figure 6: This is a digital skiagram of abdomen A-P view with lower part of chest and upper part of pelvis taken in erect posture showing omega shaped
Figure 7: This is a digital skiagram of abdomen A-P view with lower part of chest and upper part of pelvis taken in erect posture showing omega shaped
distended large bowel loop suggestive of sigmoid volvulus along with distended gas lled loops of large bowel
distended large bowel loop suggestive of sigmoid volvulus
Chapter 15: Gastrointestinal
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ierential Diagnosis
D
Other causes of large bowel obstruction
Caecal volvulus
Colonic pseudo-obstruction.
ey Points
K
Dahl froment’s sign (Coee bean/Bent inner tube appearance):
¾ In SV three distinct lines present.
¾ 2 outer lines indicate outer margins of the dilated gut loop.
¾ 1 inner line formed by intervening lines formed by two inner walls of gut.
In caecal volvulus, a kidney shaped, air lled structure is seen in left upper quadrant of abdomen on X-ray
Bird’s beak appearance seen on barium enema
Northern exposure sign: When a dilated sigmoid colon ascends to transverse colon on a supine radiograph
Insertion of atus tube may be attempted in order to decompress sigmoid colon.
BARIUM SWALLOW XRAY OF ESOPHAGUS
75
Figure 8: This is barium swallow X-ray of esophagus taken in AP, lateral and oblique positions showing partial short segmental narrowing in cricopharynx
with normal passage of barium till esophago-gastric junction. Presence of barium in tracheobronchial tree suggests the possibility of aspiration
76
Section 3: X-rays
BARIUM SWALLOW
A contrast medium, usually a radiocontrast agent such
as barium sulfate mixed with water, is ingested and X-ray
lms are taken serially
e barium enhances the visibility of the relevant parts
of the gastrointestinal tract by coating the inner wall of
the tract and appearing white on the lm
It is mainly done for esophagus related diseases.
BARIUM MEAL
is is similar to a barium swallow. However, it aims to look
for problems in the stomach and duodenum especially.
BARIUM FOLLOW THROUGH
is test is similar to a barium meal but aims to look for
problems in the small intestine
After consuming the barium liquid, wait for 10–15 min
before taking the serial X-rays. is allows time for the
barium to reach the small intestine
An X-ray might have to be taken every 30 minutes or so
until the barium is seen to have gone through the whole
of the small intestine and reached the large intestine
(colon).
ndications
I
Structural and functional abnormalities of pharynx and
esophagus which include:
Diverticula
Strictures
Polyps
Dysphagia.
ontraindications
C
Esophageal or bowel perforation
Bowel obstruction or severe constipation
Pregnancy
Severe swallowing diculty (risk of aspiration into lungs).
ACHALASIA CARDIA
Figure 9: This is a barium swallow X-ray of esophagus showing narrowing in middle and lower part of
esophagus with proximal dilatation and hold up of contrast suggestive of achalasia cardia
Chapter 15: Gastrointestinal
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ierential Diagnosis
D
Scleroderma
Esophageal malignancy
Esophageal stricture
Chagas disease
Diuse esophageal spasm.
ey Points
K
Achalasia cardia is a condition in which lower esophageal sphincter fails to relax due to loss of ganglionic cells in the myenteric
plexus
Pseudoachalasia is caused by carcinoma at the cardia or extrinsic compression of esophagus due to bronchogenic carcinoma or
metastatic lymph nodes
The appearance in barium swallow is called as Bird’s beak/Pencil tip/Rat’s tail appearance.
CARCINOMA ESOPHAGUS
77
Figure 10: This is a barium swallow X-ray of esophagus showing narrowing in middle and lower end of esophagus with irregular mucosal lining with
D
K
ulceration seen up to the fundus of stomach with proximal dilatation and hold up of contrast suggestive of carcinoma esophagus
ierential Diagnosis
As described in achalasia cardia.
ey Points
Biopsy of the lesion is done to conrm the diagnosis and CT scan to assess the extent of the disease
The appearance in barium swallow is called Rat tail lling defect in cases of severe narrowing of esophagus.
78
Section 3: X-rays
BARIUM ENEMA
Figure 11: This is a skiagram of contrast barium enema showing normal haustration and lling of sigmoid,
descending and transverse colon suggestive of a normal barium enema with no signicant abnormality
A barium enema is a type of X-ray imaging test that
allows examination of lower intestinal tract. It involves
administering a contrast solution that contains the metallic
element barium into the rectum while X-ray images of the
area are being taken.
ndication
I
Inammatory bowel diseases like ulcerative colitis and
Crohn’s disease
Strictures or diverticula of large intestine
Intussusception
Carcinoma colon
Unexplained bleeding per-rectally.
ontraindications
C
Allergy to barium
Colonic perforation
Presence of active bleeding per-rectally
TYPES
Single contrast study- Colon is lled with barium which
outlines the intestine and reveals large abnormalities
Double contrast/Air contrast study- Colon rst lled
with barium → barium drained out (only a thin layer of
barium on wall of colon is left) → colon lled with air →
detailed view of inner surface of colon.
Hepatobiliary
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T-TUBE CHOLANGIOGRAM
Chapter
16
Figure 1: This is a digital T-tube cholangiogram with T-tube in situ showing hepatobiliary tract and duodenum delineated with dye with no lling defects
in biliary ducts although a small amount of leakage of dye near the entrance of T-tube can be visualized. No other signicant abnormality is noted.
80
Section 3: X-rays
Figure 2: Similar type of T-tube cholangiogram as described in previous picture
ndication
I
Possibility of residual small CBD stones post-
choledocholithotomy
Obstructive jaundice
Bile duct stricture
Before removal of T-tube after open CBD exploration.
ethod
M
Done on 8th to 10th postoperative day
T-tube ushed with 20 ml saline
10–20 ml of urogran 60% is then injected into the
T-tube
X-ray taken (T-tube cholangiogram).
ontraindications
C
Contrast or iodine allergy
Barium study within last 3 days.
ey Points
K
Air bubble CBD stone
Perfectly round Not completely round
Dense black lling defect Not densely black
Changes position with
change of posture
Usually no change in
position with change of
posture
Genitourinary
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RENAL STONES
Chapter
17
Figure 1: This is a digital skiagram of KUB (Kidney, Ureter, Bladder) region anteroposterior view with upper part of pelvis showing multiple radiopaque
shadows in right and left paravertebral region overlying renal shadows below the 12th rib suggestive of bilateral renal calculi
82
Section 3: X-rays
Figure 2: This is a digital skiagram of KUB (Kidney, Ureter, Bladder) region anteroposterior view with upper part of pelvis showing multiple radiopaque
ierential Diagnosis
D
Renal calculi
Calcied lymph nodes
Calcied renal tuberculosis
Calcied adrenal glands
Faecoliths
10% cases of gallbladder calculus.
ey Points
K
90% renal stones are radiopaque
Renal stones:
Oxalate stones are commonly associated with hematuria due to irregular shape and sharp projections
CCU (calcium oxalate, cystine, uric acid) stones are formed in acidic urine
Struvite stones are common in females due to increased risk of UTI.
shadows in left paravertebral region overlying renal shadows below the 12th rib suggestive of left sided renal calculi
Radiopaque Radiolucent (TIXU)
Calcium oxalate stones Triamterene stones
Struvite (Triple phosphate) stones Indinavir stones
Cystine stones Xanthine stones
Uric acid stones
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