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Diagnostic EvaluationsRadiology, Nuclear Scans, PET, CT Colography

Matthew G. Mutch, Elisa H. Birnbaum, and Christine O. Menias

The goal of this text is not to provide the definitive chapter on gastrointestinal (GI)
radiology, but rather to provide a sturdy foundation for the techniques, indications,
and interpretation of radiologic imaging studies used in everyday colon and rec- tal
surgery practices. Diagnostic radiology is the application of data or image
acquisition to our knowledge of anatomy and pathology. Advances in technology
have allowed us to diag- nose many common diseases at earlier stages as well as
iden- tify new pathology previously not detectable with radiologic studies.
Plain Films
The information or picture provided by plain films is the result of differential
absorption of the X-rays by the various components of the abdominal wall, bony
skeleton, and the intraabdominal contents. In particular, it is the interfaces between
the different anatomic planes created by the inherent contrast of the various tissues
attributed to the relative fat con- tent of each structure and intraluminal gas of the
GI tract that gives the image seen on the film. It is these interfaces that allow for
the delineation of the liver edge, renal shadow, psoas shadow and differentiation of
the patterns of the stomach, small bowel, and colon. The typical flat plate X-ray
uses 6075 kV to expose each film. This varies depending on the equipment used
and the size of the patient. A reciprocating grid and collimation are used to reduce
scatter of the radiation and improve tissue contrast. Controversy exists over the
number of views or films needed to adequately examine the abdomen. Classical
teach- ing recommends three views consisting of a supine abdomen, upright or
lateral decubitus abdomen, and upright chest. The rationale for these films is as
follows1: 1) the supine abdomen offers the most detail and contrast of the
intraabdominal struc- tures; 2) the upright or decubitus abdominal views allow for a
change in intraluminal gas distribution and identification of extraluminal free-air; 3)
the upright chest contributes diag- nostic information in 20% of cases.2 However,
Mirvis et al.3
argued that the upright abdominal view was unnecessary. They reviewed 252
examinations and found that the supine abdominal and upright chest films alone
provided the diagno- sis 98% of the time. Whether two or three films are obtained is
of secondary importance as long as the entire abdomen is viewed and the
examination is able to address the clinical sce- nario in question. Plain films clearly
do not offer as much anatomic detail as the cross-sectional imaging modalities, but
they remain highly sensitive and specific when there is suspicion of a bowel
obstruction or a perforated viscus.4 Other useful indi- cations for plain films include
longitudinal examination of megacolon, identification of foreign bodies, check
positions of drains or catheters, and evaluation of associated skeletal diseases.

Intestinal Obstruction
Small Bowel Obstruction
Investigation of intestinal obstruction, whether it is small ver- sus large bowel or
mechanical versus functional, is a common indication for abdominal plain films. The
signs and symptoms of a small or large bowel obstruction depends on the location
and extent of the obstruction and can include nausea, vomit- ing, abdominal pain,
abdominal distention, and obstipation. Just as the clinical manifestations of the
obstruction depend on its location so do its radiographic findings. Duration of
symptoms, significant emesis, use of a nasogastric tube, and degree of obstruction
also contribute to the radiographic appearance of a bowel obstruction. With regard
to small bowel obstruction (SBO), the most common causes in descending order are
adhesions, Crohns disease, neoplasia, and hernia.5 Abdominal plain films have
been shown to be diagnostic in 50%66% of cases with approximately 20% falsenegative rate.4 The radiographic diagnosis of an SBO depends on the intraluminal
gas pattern projected upon the plain film. A nor- mal gas pattern is defined as small
amounts of gas distributed