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Radiology (dra Bandong

GI Radiology

19 July 08

From doc Bandong’s own words:  Acute pancreatitis: echomogenous (echomogenous?!

 Ultrasound of the whole abdomen, there is Wala na cranky na ko haha) enlarged pancreatitis or
perforation, put in NPO for patients who have no possibility of pseudo-cyst, does not have severe
history of cholecystectomy. Because we want the abdominal pain
gallbladder to be distended in order to evaluate it.  Chronic pancreatitis and pancreatic CA have both
 The patient will not eat or have his breakfast, the calcification on the pancreas. So rule out pancreatic
gallbladder will be contracted because of the bile CA first. But in some cases, there are different types
because you’re bile contains those that will of (tpos nawala na lang sya hahahaha)
breakdown the fat. Patient should be NPO atleast 4-6  Normal GB wall: less than 3mm
hours.  Status post cholecystectomy
 Normal gallbladder: less than 5 cm in diameter  Liver CA: rule out if there is PV thrombosis, the normal
o More than 5: hydrops size of the spleen is 11x5 cm. more than that: Ddx:
 Normal wall of gallbladder: around 3 mm lymphoma or leukemia
o Thickened wall with adjacent fluid in the GI wall:  Calcification in the liver and spleen: first impression
cholecystitis would be kidney (sobrang di cguro eto yung snabi
 Ultrasound: stones will appear as white nya) if patient is Filipino
 X-ray: stones will also appear as white
**natapos din! Churi churi I tried my best, but I guess my
 Common radiographic finding for cholecystolithiasis
best was not good enough. Haha. Natorture yung tenga
is: inter-luminal stones, wall would be thickened
ko dun a. happy aral! Panimula palang yan kala nyo
 Stones in common bile duct of gallbladder: haha!
choledocholithiasis (please check kung tama, di ko –isay-
masyado maintindihan)
 Stones in gallbladder: cholecystolithiasis ANATOMY
 Stone in common bile duct: check intra-hepatic ducts, ESOPHAGUS
particularly in region of area of the pancreatic duct  muscular tube between 6th vertebral body
 Liver is mainly supplied by portal vein. (cricopharyngeus) and 10th - 12th thoracic vertebra
 Mass in liver: check portal vein if there is possibility of (just below the diaphragm).
metastasis or a visual ____(may dumaldal, dko narinig  It measures 25-30cms in adults.
na haha) in CBD that would cause portal vein
thrombosis  Esophagus is divided into 3 parts:
 Portal vein size: 1.2 i) cervical (5cm) - lies behind the trachea ,
 CBD size: 0.7 cm ii) thoracic (20cms) - extends from the
 In patients with previous cholecystectomy, size of thoracic inlet into the posterior mediatinum;
CBD would be 1 cm. and
 In liver cirrhosis, the left lobe of the liver is enlarged, iii) abdominal (1-3cms) - starts where
right lobe would be smaller and the margin of the esophagus passes through the diaphramatic
conture of the liver would be nodular, epigenicity of hernia.
the liver parenchyma is coarsened (jassie on tape:
coarse? Coarse?) hahahaha . 3 esophageal constrictions
 Liver cirrhosis: Common feature: small liver with  Uppermost - caused by cricopharyngeal muscle
nodular and coarsened pattern with ascites  Middle - where esophagus is crossed by aortic arch at
 Importance for requesting for MRI: tracheal bifurcation
o In patients who has acute renal failure, we  Lowermost - caused by gastroesophageal sphincter
at the esophageal hiatus of the diaphragm
cannot give contrast materials because the
minimum contrast material to be given on CT
scan would be 16 ml, on MRI it’s I think 5-10 cc.
 Structure: barum enema or UGI series, but rule out
lower obstruction so barium enema first then UGI
 Most common reason why (peste! Peste! Kahit sa
tape di sya maintindihan peste! Haha) emergency
request for UTZ for cholecystitis: because GB may be
distended more than 8-10 cm, surgical er may be
needed. Also to rule out stones in kidney or GB. And
to rule out if there is abdominal pain (WTF?!)
 What are the common sonographic finding of acute
cholecystitis: thickened wall, possibly a stone, and
shar 1 of 20
Radiology – GI Radiology by Dra Bandong Page 2 of 20

 Duodenum -- approximately 25 cm long; proximal

end of small intestine; joined to stomach by the
pyloric sphincter.
 Jejunum -- approximately 200 cm long.
 Ileum -- approximately 300 cm long; joins the cecum
at the ileocecal valve


1. Body of stomach
2. Fundus
3. Anterior wall
4. Greater curvature
5. Lesser Curvature
6. Cardia
9. Pyloric sphincter
10. Pyloric antrum
11. Pyloric canal
12. Angular notch
13. Gastric canal
14. Rugal folds

Small Intestine
 The is a tube measuring about 2.5 cm in diameter.
 The complete small intestine is approximately 600 cm
(20 feet) long and coiled in loops, which fill most of
the abdominal cavity.
 It extends from the pyloric sphincter to the ileocecal *Top: Gas in the stomach
valve *Left: Free Gas in the small bowel
*Right: gas in the rectum/sigmoid

*Right: Always air-fluid level in the stomach

*Left: Few air-fluid levels in the small bowel
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o Peripheral
o Haustral markings do not extend from wall to
o Central
o Valvula extend across the lumen
o Maximum diameter of 2”

Abnormal gas patterns

 Functional ileus
o Localized (sentinel loops)
o Generalized adynamic ileus
 Mechanical obstruction
o Small bowel obstruction (SBO)
o Large bowel obstruction (LBO)
Air in Air in Air in
Rectum or Small Large
Sigmoid Bowel Bowel
Air in
Localized rectum
Yes distended
Ileus or
Multiple Yes-
Yes distended distend
d Ileus
loops ed
dilated loops
None –
Yes -
LBO No ileocecal
 May resemble early mechanical SBO
o Clinical course
o Follow up

 Gas in dilated small and large bowel down to the
 Long air fluid levels
 Only post-op patients have generalized ileus
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o Tumor
o Volvulus
o Hernia
o Diverticulitis
o Intussusception
 Incompetent ileocecal valve
o Large bowel decompression into the small bowel
o May look like SBO
o Follow up study
o Barium enema
o Air goes to small bowel
o Request for barium enema
 To rule out obstruction
 Barium hardens
o If no LBO, do SGIS
o Dilated segments

Small bowel obstruction

 Adhesion, hernias, etc.

 > 5cm, distended
 CAUSES Gallstone Ileus
o Adhesions  Air in biliary tree
o Hernia  Stone in ileocecal valve
o Volvulus
o Gallstone ileus
o Intussusceptions

Generalized Adynamic Ileus

 distended

Mechanical LBO
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Sigmoid Volvulus
 Distended sigmoid

 Cause is generally considered a defect in the

cholinergic receptors of Auerbach’s plexus (between
the inner circular and the outer longitudinal muscle
layers of the muscularis).
 Characteristically, primary peristaltic stripping waves
are absent in either the upper (early) or the whole
(late) esophagus. Tertiary waves may be present but
in the late stages the esophagus is atonic. The lower
esophageal sphincter fails to relax.
 In the late stages, the distal esophagus tends to
make a right angle bend before entering the stomach
due to the extreme tortuosity of the esophagus. This
is called “bird’s beak” or “rat-tail” sign.

Cecal Volvulus




- to rule out pathology in the esophagus ANTRUM
2. AP Projection
- hypopharynx

Radiology – GI Radiology by Dra Bandong Page 6 of 20

 Allows you to visualize the gastric antrum and the

duodenal cap while being able to sweep in double  This view is like the compression of the antrum in
contrast phase single contrast. The fundus is in double contrast and
the duodenal sweep is sometimes seen to a better

 This view will provide you a double contrast view of

the anterior wall of the stomach and sometimes of
the posterior portion of the fundus LEFT POSTERIOR OBLIQUE VIEW OF THE
 There is a lesion on the posterior wall (Arrow) DUODENUM



 the patient in LPO position will demonstrate the

duodenal cap and the rest of the duodenum in
double contrast.
Radiology – GI Radiology by Dra Bandong Page 7 of 20



Two main types:

1. Sliding Hiatal Hernia (99%)
 EG junction lies above the diaphragm, or
 Distal most esophagus measures more than 50% of
the diameter of the tubular esophagus=patulous
cardia=predisposed to GE reflux, or
 Prominent gastric folds extend into distal esophagus  Most commonly involves terminal ileum
from stomach  Bowel wall becomes markedly thickened and
 May be reducible or incarcerated; sliding refers to EG submucosa infiltrated (picket-fence)
junction, not to reducibility  “Thumb-printing“ may be seen
2. Paraesophageal Hiatal Hernia  Loops are widely separated and there may be mass
 Portion of stomach herniates through esophageal effect
hiatus above diaphragm but EG junction continues to  Another form may have a large ulceration which is
be subdiaphragmatic confined and produces so called “aneurysmal
 Usually non-reducible dilatation” of the bowel
 Not associated with GE reflux



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• Rectal bleeding : gross or occult
• Polyps or carcinoma: suspected or known
• Inflammatory Bowel Disease: suspected or known
• Patient over 40y/o who can cooperate and turn over
ASCARIASIS without assistance


• Suspected acute perforation
• Acute fulminating colitis
• Immediately after biopsy

Sigmoid Colon

 Most common parasitic infestation in the world

 Most common in children ages 1 to 10 years
 Most often found in distal small bowel

Life cycle
• Infection is through contaminated soil
• Involves GI tract of host twice
• First time as egg
• Migrates through lungs
• Adult travels up trachea
• Returns to GI tract for maturation (2 months)

X-ray findings
Rectosigmoid Colon
• Long, tubular filling defects, especially in distal small
• The worm ingests barium and the barium may be
seen as a thin line of contrast in the center of the
• Especially after the remainder of the barium exits the
small bowel. See below (streak of barium in LUQ):

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• Suspected perforation or high-risk for intestinal
• Therapeutic enema for disimpaction (after failure of
routine cleansing enemas)

Hepatic Flexure

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(usually requires >1,000 mL of free intraperitoneal

gas + intraperitoneal fluid)
5. "Telltale triangle sign" = triangular air pocket between
3 loops of bowel
6. Depiction of diaphragmatic muscle slips = two or
three 6-13 cm long and 8-10 mm wide arcuate soft-
tissue bands directed vertically inferiorly + arching
parallel to diaphragmatic dome superiorly outline of
ligaments of anterior inferior abdominal wall:
7. "Inverted V sign" = outline of both lateral umbilical
ligaments (containing inferior epigastric vessels)
8. Outline of medial umbilical ligaments (obliterated
umbilical arteries)
9. "Urachus sign" = outline of middle umbilical ligament

RUQ gas
1. Single large area of hyperlucency over the liver
2. Oblique linear area of hyperlucency outlining the
posteroinferior margin of liver
3. Doge's cap sign = triangular collection of gas in
Morison pouch (posterior hepatorenal space)
4. Outline of falciform ligament = long vertical line to
the right of midline extending from ligamentum teres
notch to umbilicus; most common structure outlined
5. Lligamentum teres notch = inverted V-shaped area of
hyperlucency along undersurface of liver
6. Ligamentum teres sign = air outlining fissure of
ligamentum teres hepatis (= posterior free edge of
falciform ligament) seen as vertically oriented sharply
defined slitlike / oval area of hyperlucency between
10th and 12th rib within 2.5-4.0 cm of right vertebral
border 2-7 mm wide and 6-20 mm long
7. "Saddlebag / mustache / cupola sign" = gas trapped
below central tendon of diaphragm
8. Parahepatic air = gas bubble lateral to right edge of
…sobrang di ko alam kung san isisngit ang mga ito kaya liver
dito na lang sila…tapos mya ibang pics na di ko nailagay
kasi walang labels sa slide…ayun… CARCINOMA OF THE ESOPHAGUS
• Squamous cell ca (95%)
FREE INTRAPERITONEAL AIR • Adenocarcinoma arising from heterotopic gastric
(PNEUMOPERITONEUM) mucosa or columnar-lined epithelium (Barrett’s)
• Large, bulky, polypoid intraluminal mass which may
Etiology be pedunculated - Mucoepidermoid carcinoma
1. Disruption of wall of hollow viscus • Spread is facilitated by the esophagus’ lack of a
• Blunt or penetrating trauma, serosa
• Iatrogenic perforation
• Diseases of GI tract
Upper 1/3 20%
• Perforated gastric / duodenal ulcer, appendix,
Diverticulitis, Middle 1/3 50%
• Necrotizing enterocolitis with perforation,
Inflammatory bowel disease Lower 1/3 30%
2. Through peritoneal surface
• Transperitoneal manipulation, Abdominal needle Radiologic types
biopsy / catheter placement • Polypoid/fungating form (most common)
o Sessile, polyp
Imaging findings o Apple-core lesion
1. Large collection of gas • Ulcerating form
2. Abdominal distension, no gastric air-fluid level o Large ulcer within mass
3. "Football sign" = large pneumoperitoneum outlining • Infiltrating form
entire abdominal cavity o Gradual narrowing resembling benign stricture
4. "Double wall sign" = "Rigler sign" = air on both sides
of bowel as intraluminal gas and free air outside
Radiology – GI Radiology by Dra Bandong Page 11 of 20

• Squamous cell carcinomas of the distal esophagus • Scalloped esophageal luminal masses
almost never invade the stomach whereas • Right- / left-sided soft-tissue masses =
adenocarcinomas arising from a Barrett’s does paraesophageal varices
• Marked enhancement following dynamic CT
• To lymphatics-especially supraclavicular nodes GASTRIC ULCER
• Hematogenous: lung, liver, adrenal
• Lesser curvature aspect of body and antrum usually
ESOPHAGEAL VARICES for benign ulcers
• Dilated submucosal veins due to increased collateral • Benign ulcers also occur on posterior wall; not usually
blood flow from portal venous system to azygos anterior wall
system • May be found in proximal half of stomach in geriatric
1. Uphill varices patient
• Collateral blood flow from portal vein via azygos vein • Almost all lesser curvature gastric ulcers <1cm are
into SVC (usually lower esophagus drains via left benign
gastric vein into portal vein) • Greater curvature benign ulcers are associated with
• Most common cause is portal hypertension secondary considerable mass effect which erroneously leads to
to cirrhosis conclusion of malignancy
• Varices in lower half of esophagus to the level of the
carina (azygous vein) X-Ray Signs of a benign gastric ulcer
• Ulcer crater-collection of barium on dependent
• More common than downhill varices
surface which usually projects beyond anticipated
• Causes:
wall of stomach in profile (penetration)
o Intrahepatic obstruction from cirrhosis • Hampton’s line-1 mm thin straight line at neck of
o Splenic vein thrombosis (usually gastric varices ulcer in profile view which represents the thin rim of
only) undermined gastric mucosa
o Obstruction of hepatic veins • Ulcer collar-smooth, thick, lucent band at neck of
o Portal vein thrombosis ulcer in profile view representing thicker rim of
o IVC obstruction below hepatic veins edematous gastric wall
o Marked splenomegaly / splenic hemangiomatosis • Ulcer mound-smooth, sharply delineated tissue mass
(rare) surrounding a benign ulcer
• Ring shadow-thin rim of contrast which represents an
2. Downhill varices ulcer on the non-dependent surface of an air-contrast
• Collateral blood flow from SVC via azygos vein into study
IVC / portal venous system (upper esophagus usually • Thickened folds radiating directly to the base of the
drains via azygos vein into SVC) ulcer en face
• Varices in upper 1/3 of esophagus
• Usually extend down to the level of the carina X-ray signs of malignant ulcers
(azygous vein) • Ulcer projects within the anticipated wall of the
• Less common than uphill varices stomach
• Ulcer is eccentrically located within the ulcer mound
• Causes:
• Irregularly shaped ulcer crater
o Obstruction of superior vena cava distal to entry
• Nodular ulcer mound
of azygos vein due to • Abrupt transition between normal and abnormal
o Lung cancer (most common) mucosa several cms away from the ulcer crater
o Lymphoma • Rigidity, lack of distensibility and lack of changeability
o Retrosternal goiter • Associated large mass
o Thymoma • Carmen meniscus sign-a relatively shallow gastric
ulcerating malignancy projecting as an ulcer which is
PLAIN FILM always convex inwards to the lumen and which does
• Lobulated masses in posterior mediastinum (visible in not project beyond the wall=Kirklin meniscus complex
a small percentage of patients with varices)
• Silhouetting of descending aorta CARCINOMA OF THE STOMACH
• Abnormal convex contour of azygoesophageal recess Histology
• Adenocarcinoma (95%)
UPPER GI SERIES • Rarely, squamous cell
• Thickened and interrupted mucosal folds (earliest
sign) Morphology
• Tortuous radiolucencies of variable size and location • Polypoid/fungating carcinoma
• "Worm-eaten" smooth lobulated filling defects • Ulcerating/penetrating carcinoma (70%)
• Infiltrating/scirrhous type=linitis plastica
CT SCAN • Superficial spreading type-confined to
mucosa/submucosa-NOT linitis plastica
• Thickened esophageal wall and lobulated outer
Radiology – GI Radiology by Dra Bandong Page 12 of 20

Metastases Complications
• Along peritoneal ligaments - Hemorrhage 15%
o Gastrocolic ligament to transverse colon melena>hematemesis
o Gastrohepatic and hepatoduodenal to liver - Perforation <10%
• To lymph nodes anterior>posterior /
o Locally - Obstruction 5%
o Lymphangitic to lungs - Penetration <5% walled-
off perforation
• Hematogenous
o Liver (most common)/adrenals/ovaries/bones
• Peritoneal seeding
o Rectal wall=Blumer shelf
• Left supraclavicular node=Virchow’s node
Malignant ulcer—is a carcinoma which presents with Sprue
the radiographic appearance of an ulcer niche; these • 3 diseases: Celiac Disease of Children, Nontropical
have the radiographic appearance of a benign ulcer but sprue and
demonstrate microscopic foci of malignancy, usually at
the edge of the ulcer Tropical Sprue
• Celiac disease and Nontropical sprue improve on
Ulcerating malignancy—is a carcinoma having gluten-free diet
sufficient bulk to present as a mass which also contains a • Tropical sprue improves with antibiotics and folic acid
persistent collection representing an ulcer; the mucosa is
frequently nodular and the folds do not radiate to the X-ray
base of the ulcer • The hallmark features are: dilatation and dilution,
especially in jejunum
Linitis plastica (scirrhous carcinoma)—is a diffuse • Segmentation of the barium column occurs because it
involvement of the wall of the stomach, frequently with moves more slowly through areas of excessive fluid
flattening of the mucosa, and poor distensibility and and separates from the rest of the column-not
contraction of the wall; usually associated with significant commonly seen with newer barium mixtures
fibrosis and muscular hypertrophy; very frequently a • Fragmentation is an exaggerated example of the
signet ring cell type irregular stippling of residual barium in the proximal
bowel (which is normal)
DUODENAL ULCER DISEASE • Intussusception is not uncommon but is usually not
• 2-3 times more frequent than gastric ulcers obstructive; sprue has increased risk of ca and
• 3:1 male:female ratio lymphoma
• Moulage sign is caused by dilated loop with effaced
Pathophysiology folds looking like tube into which wax has been
• Excessive acidity in duodenum from poured
• Abnormally high gastric secretion
• Inadequate neutralization Scleroderma
• Affects esophagus, small bowel and colon, sparing the
Location stomach
• Bulbar (95%) • Atrophy of the muscular layers and replacement with
o Anterior wall– 50% fibrous tissue
o Posterior wall– 23% • Associated with malabsorption
o Inferior fornix– 22%
o Superior fornix– 5% X-ray
• Postbulbar (3-5%) • Whole small bowel is usually dilated with close
o Majority on medial wall just proximal to ampulla approximation of the valvulae (hide-bound
o Tendency for hemorrhage in 66% appearance) (stack-of-coins)
o Male:female ration 7:1 • Does not have increased secretions as does sprue
• May be associated with pneumatosis intestinales
• Small round, ovoid or linear crater Whipple’s Disease
• Glycoprotein in the lamina propia of the small bowel
• Kissing ulcers–ulcers opposite from each other on the is Sudan-negative, PAS-positive
anterior and posterior walls
• Clinically: arthralgia, abdominal pain, diarrhea and
• Giant duodenal ulcer–>3cm (rare) with higher weight loss
morbidity and mortality • Treated with long term antibiotics-penicillin
• May be mistaken for the duodenal bulb itself and • Very rare
• Clover-leaf deformity–healed central ulcer of the bulb X-ray
with four-leaf clover-like deformity remaining • The hallmarks of the disease are nodules and a
markedly thickened bowel wall (picket-fence)
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• Small bowel may or may not be dilated • Changes are identical to ischemia since radiation
• Affects jejunum mostly changes are actually secondary to an arteritis with
occlusion of small vessels
Amyloidosis • Localized to area of radiation portal, especially pelvis
• GI involvement is common in female 2° endometrial carcinoma treatment
• Associated with malabsorption • Previous adhesions from surgery may anchor small
bowel in pelvic portal and predispose to XRT changes
X-ray • Mucosa is most sensitive to radiation
• Marked thickening of the valvulae (picket-fence) X-ray
• No dilatation or dilution • Localized thickening of the folds 2° edema and
• Affects entire small bowel hemorrhage
• May result in strictures later in course
• Hypoalbuminemia resulting from liver or kidney Sigmoid Volvulus
disease lower than 1.5 grams per cent • Twisting of loop of intestine around its mesenteric
• Usually asymptomatic from intestinal edema itself attachment site may occur at various sites in the GI
X-ray o Most commonly: sigmoid & cecum
• Changes are present throughout small bowel o Rarely: stomach, small intestine, transverse colon
• Loops are separated due to edema of walls o Results in partial or complete obstruction
• Folds are quite thick (picket-fence) o May also compromise bowel circulation resulting
in ischemia
Giardiasis • Sigmoid volvulus most common form of GI tract
• Giardia lamblia is a flagellated protozoan, a normal volvulus
parasite of the small bowel • Accounts for up to 8% of all intestinal obstructions
• Clinically: diarrhea and malabsorption • Most common in elderly persons (often neurologically
• Treated with metronidazole (Flagyl)
• Some patients have hypogammaglobulinemia and
nodular lymphoid hyperplasia associated with

Abdominal plain films usually diagnostic
• Usually limited to duodenum and jejunum 1. Inverted U-shaped appearance of distended sigmoid
• Thickening of the folds loop
• Marked spasm and irritability of the bowel • Largest and most dilated loops of bowel are seen
• • Increased secretions is common with volvulus
2. Loss of haustra
Ischemic Bowel Disease 3. Coffee-bean sign midline crease corresponding to
• Thickening of the wall due to edema and hemorrhage mesenteric root in a greatly distended sigmoid
• Localized perforations can produce air in the bowel • Sigmoid volvulus – bowel loop points to RUQ
wall or in portal venous system
• Cecal volvulus – bowel loop points to LUQ
• Spasm and irritability early is replaced by an atonic • Dilated cecum comes to rest in left upper
bowel later quadrant
• Lumen is narrowed 4. Bird’s-beak or bird-of-prey sign seen on barium
• Folds are thickened, sometimes producing “thumb- enema as it encounters the volvulated loop
printing” • CT scan useful in assessing mural wall ischemia
• Healing may result in stricture formation
Air beneath the diaphragm
Intramural Bleeding Upright chest radiograph shows a large
• Suggested if there is duodenal obstruction following pneumoperitoneum outlining the spleen and the superior
trauma surface of the liver.
• Localized lesions occur with trauma
• Diffuse lesions are seen with anticoagulants

• Uniform, regular, thickening of the folds
• Separation of the loops
• Mass effect
• No spasm

Radiation Enteritis
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Supine abdominal radiograph shows an elliptical

collection of air within the subhepatic space.

Coned view of the lower abdomen shows the lateral

umbilicus sign (arrow), which is a sign of a large
pneumoperitoneum on a plain abdominal radiograph

Diagram of the right upper quadrant shows a triangle-

shaped collection of air in the Morison’s pouch, as seen
on a plain supine abdominal radiograph. This collection is
usually bound by the 11th rib, and it may be triangular
(doge’s cap), crescent shaped, or semicircular.

Rigler’s Sign

Right: air on both sides of the bowel wall

Diagrams of the right upper quadrant show the location of Left: Normal
the oblong collection of air in the right subhepatic space
seen on a plain supine abdominal radiograph
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Soft Tissue Masses

• Hepatosplenomegaly
• Tumor or cyst
o Bowel displacement
 Paucity of gas Mass in Cologastric Space
 Pad sign – extrinsic compression of bowel


Pancreatic pseudocyst

Myoma Uteri

Renal Cyst

Bowel Outlet Obstruction

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RLQ Abscess

• Rimlike
• Linear or track like
• Lamellar
• Cloudlike

Rimlike Calcification - Wall of a hollow viscus

• Cysts
o Renal cyst
• Aneurysms
o Aortic aneurysm
• Saccular organs
o GB

• Gallstones affect 10-15% of the population and are a
major cause of gallbladder (GB) morbidity.
Symptomatic gallstones presents with characteristic
right upper quadrant discomfort or pain (biliary colic).
Most gallstones are mixtures of cholesterol, calcium
bilirubinate, and calcium carbonate
• Sonographic Diagnosis:
o Echogenic foci in GB lumen
o Acoustic shadowing
o Rolling stone sign – movement of gallstones with
GB with position change
Lamellar or Laminar – formed in lumen of a hollow
• Nephrolithiasis
• Cholecystolithiasis
• Cystolithiasis
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Gallstones (red arrow) within the gallbladder produces a

bright surface echo and causes a dark acoustic shadow With the patient in left lateral decubituis position, the
(S) gallstone (red arrow) rolls to the gallbladder fundus.

Acute Cholecystitis
• Most commonly caused by impaction of a gallstone in
the gallbladder (GB) neck obstructing the GB and
resulting in inflammation of the GB wall.
• Patients present with pain, RUQ tenderness, and
• About 70% of patient with acute cholecystitis have
diffuse wall thickening
• Diffuse and marked wall thickening can also be seen
in ascites, pancreatitis, hepatitis, CHF, sepsis, and

Diagnosis for Acute Cholecystitis

• Major Criteria
o Gallstones
o Sonographic Murphy’s sign
• Minor Criteria
o Wall thickening >3mm
o Pericholecystic fluid

Normal Study

With the patient supine, the gallbladder (red arrow) is

near the neck of the gallbladder. • GB demonstrates the gallbladder neck (red arrow)
• GB wall thickness is measured between the
gallbladder lumen and the hepatic parenchyma (red
arrowheads) with normal thickness < 3 mm
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Transverse image reveals dilated bile duct (red arrow)

The gallbladder (GB) is filled with echogenic sludge and a anterior to the portal vein (red arrowhead) resembling a
gallstone (red arrow) is impacted in the gallbladder neck. double-barrel shotgun
The gallbladder wall (red arrowheads) is markedly
thickened indicative of wall edema and there are
pericholecystic fluid (blue arrows) pockets surrounding
the gallbladder.

Sonographic Findings:
1. Shotgun sign in intrahepatic biliary ducts (IHBD)
become tortuous and their diameter exceeds 2 mm or
exceeds 40% of the diameter of the adjacent PV.
Color Doppler is used to confirm the absence of blood
flow in the enlarged biliary tubes
2. Confluence of enlarged intrahepatic biliary ducts
create a stellate appearance of merging tubes
3. CBD is considered diluted in adults if its diameter > 7

Dilated IHBD (red arrows) are seen as tortuous tubular

structures in the liver. Color Doppler makes differentiation
of bile ducts (red arrows) and blood vessels (red
arrowheads) easy.

Dilated common bile duct (red arrow) measured at 9.7

In the transverse image, the common bile duct (red mm
arrowheads) is anterior to the portal vein and the
gallbladder (red arrow) is also visualized. EPIGASTRIC PAIN
Shotgun Sign • Most commonly caused by alcohol abuse or a
gallstone impacted in the distal common bile duct.
• Inflammatory changes vary from mild interstitial
edema to extensive necrosis with hemorrhage
• Patient usually presents with deep epigastric pain that
radiates to the back, nausea, vomiting, abdominal
tenderness, fever, leukocytosis, and elevated
pancreatic enzymes
• Pancreatic pseudocysts are sometimes found several
weeks after pancreatitis

Sonographic Findings:
1. Diffuse enlargement of pancreas with ill-defined
margins and hypoechoic parenchyma
Radiology – GI Radiology by Dra Bandong Page 19 of 20

2. Peripancreatic fat decreased in echogenicity with

hypoechoic stranding densities
3. Hemorrhage may cause hyperechoic masses of clot of
4. Peripancreatic fluid collections in lesser sac, perirenal
areas, and small bowel mesentery

The pancreas is recognized by identifying its adjacent

vasculature: Huge fluid collection (F) surrounding the pancreas (P)

RLQ Pain

• The classic presentation is of a 10-30 year old person
with right lower quadrant pain, nausea, vomiting, and
leukocytosis. The presence of fever is evidence of

• Inferior vena cava (V), abdominal aorta(A), and the

superior mesenteric artery (a)
• The junction of the splenic vein (SV) with the superior
mesenteric vein marks the commencement of the
portal vein (PV) and is recognized by its teardrop
• The head (H), body (B), and tail (T) of the pancreas
course anterior and parallel to the splenic vein (SV)

Transverse image reveals normal appendix (between red

arrows and + cursors) and its echogenic submucosa (red
The head of the pancreas (H) is enlarged as revealed by
the red arrowheads and decreased in echogenicity Sonographic Diagnosis:
because of edema. The surrounding structures are • Visualization of an aperistaltic tubular structure > 6
superior mesenteric vein (v), superior mesenteric artery mm in diameter or visualization of an appendix with a
(A), and inferior vena cava (IVC). fecolith confirms the diagnosis
• Generally, the abnormal appendix is not at all subtle
• The wall appears hyperechoic and may be strikingly
so with impending perforation
• A loculated fluid collection may represent abscess
from a perforated appendix or other bowel source
such as IBD (ischemic bowel dse) , or GYN source
such as TOA (tubo-ovarian abscess)
Radiology – GI Radiology by Dra Bandong Page 20 of 20

Transverse image reveals an 8 mm diameter, non-

compressible appendix (between red arrow)

An obstructing appendicolith (red arrow, between +

cursors) casts an acoustic shadow (S) and obstructs and
dilates the appendix (A) resulting in acute appendicitis.

Image in the long axis of the appendix shows long

segment loss of visualization of the submucosa (red
arrowhead) and a focal perforation (red arrow).