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RADIOLOGI

GASTROINTESTINAL:
FOTO
KONVENSIONAL

dr. Herman P. L. Wungouw, Sp.Rad

Dept. Radiologi FK Undana, Kupang


Foto Polos Abdomen

Apa yang dievaluasi ?

 Udara usus
 Udara ekstralumen
 Massa jaringan
lunak
 Kalsifikasi
Udara Normal

Selalu ada di:


 Lambung.
 Usus halus :
 2 atau 3 loop usus yang
tidak dilatasi
 Diameter normal = 2,5
cm
 Kolon :
o sigmoid dan rektum.
Fluid level normal

 Gaster:
 Selalu ada (kecuali
posisi supine)
 Usus halus:
 Ada : 2 atau 3
 Usus besar:
 Umumnya tidak ada
Large vs Small Bowel
Large Bowel:
 Di perifer  pigura foto
 Haustra : garis tidak utuh
dari dinding ke dinding.
 Diameter : > 5 cm

Small Bowel
 Di sentral
 Valvulae conniventes :
garis utuh melewati lumen
 Diameter < 2,5 cm.
Ileus ?  Abd 3 posisi.
 AP Supine
 Prone atau lateral
 Erect atau LLD

 + Chest -
erect atau supine
Posisi apa untuk menilai apa ?

 Posisi AP Supine :  Erect atau LLD:


 Penyebaran udara usus,  Udara bebas
 Kalsifikasi  Air-fluid level
 Massa soft tissue  Chest - erect or supine
 Prone atau lateral :  Udara bebas
 Udara subdiafragma
di rektum/sigmoid  Basal pneumonia
 Udara di kolon asendens  Efusi pleura
dan desendens
Abnormal Gas Patterns

 Functional Ileus :
 Localized ileus (Sentinel Loops)

 Generalized (adynamic) ileus

 Mechanical / Obstruction Ileus:


 SBO

 LBO
Laws of the Gut
 Loops proximal dari titik
obstruksi akan dilatasi.
 Loops distal dari obstruksi
akan kolaps (dekompresi)
atau tidak ada udara.
 Loop yang paling lebar
merupakan tanda dari:
 Usus yg paling awal distensi.
 Proksimal (paling dekat) dari
titik obstruksi.
Perbedaan penyebaran udara usus

Udara rektum /
Udara usus halus Udara kolon
sigmoid

Distensi 2-3 loops Udara di rektum /


Localized Ileus + usus sigmoid (+)

Generalized Ileus
+
Distensi multipel +
(Paralytic Ileus) loops usus Distensi

Dilatasi multipel
SBO - loops usus -
Tidak ada, kecuali
LBO - katup ileosekal +
inkompetent Dilatasi
Sentinel Loops
 Distensi fokal lengkung usus halus

Lokasi SL  menentukan kelainan


Localized ileus
 Menyerupai tanda awal mechanical SBO.
 Diperlukan klinis pasien.
 Pemeriksaan lain.
 Follow up.

supine erect
Generalized Ileus (Ileus paralitik)

 Dilatasi usus halus dan


usus besar sampai
rektum.
 Air-fluid levels yang
panjang-panjang.
 Post operasi
(Only post-
op patients have
generalized ileus!)
Mechanical SBO

 Dilatasi usus halus Penyebab :


 Loops usus banyak dan  Adesi (perlekatan)
tumpang tindih  Volvulus
 Udara minimal atau  Hernia
tidak ada udara di
 Gallstone ileus
kolon, terutama
rektum.  Intususepsi
 Dilatasi yang
disproporsi dari usus
halus.
Mechanical LBO

 Dilatasi kolon proksimal dari Penyebab:


lokasi obstruksi  Tumor
 Udara di rektum/sigmoid  Volvulus
minimal atau tidak ada.  Hernia
 Udara di usus halus minimal
 Divertikulitis
atau tidak ada (apabila
katup ileosekal masih  Intususepsi
kompeten).
Katup ileosekal inkompeten:

 Dilatasi usus halus dan


kolon, menyerupai
SBO  ok dekompresi
udara kolon ke usus
halus.
 Udara di
rektum/sigmoid tidak
ada.
 Dipastikan dengan
Barium Enema.
 Obstruksi pada
sigmoid.
 Pemeriksaan Barium
enema  terjadi
obstruksi total di
sigmoid.
Catatan penting:

 Tidak ada istilah pola udara usus


yang “non-spesifik”.
 Yang ada : apakah normal atau
abnormal.

 Adynamic ileus, hanya terjadi pada


pasien post operasi.
UDARA EKSTRALUMEN

Yaitu:
 Udara bebas intraperitoneal
 Pneumoperitoneum
 Tanda perforasi hollow viscus.

Tanda pada x-ray:


 Udara di bawah diafragma
 Udara diantara dinding usus (Rigler’s sign).
 Gambaran ligamentum falsifarum (football sign).
UDARA EKSTRALUMEN
Penyebab:
 Ruptur organ berongga intra abdomen :
 Ulkus
 Divertikulitis.
 Karsinoma
 Trauma
 Atau Instrumentasi.
 Post operasi (5-7 hari, udara sudah tidak ada).

NB: perforasi appendix  tidak ada udara bebas.


Soft Tissue Masses

 Hepatosplenomegaly
 (Ctt: mengukur hepar
pd foto polos tidak
tepat).
 Tumor padat atau
kista
 Pendorongan udara
usus
 Tampak kesuraman
 Kompresi ekstrinsik
udara usus
Hours later

Bladder outlet obstruction. Pre and post catheter


Kalsifikasi
Pola kalsifikasi:
 Rimlike
 Linear or track like
 Lamellar
 Cloudlike
Rimlike Calcification
 Pada dinding:
 Kista  kista ginjal
 Aneurisma  aneurisma
aorta
 Organ berkantong  KE
 Porcelain GB

eggshell calcification
Linear or Tracklike Calcification

 Dinding organ
berbentuk tabung
 Ureter
 Arteri / vena
 Vas Deferens
Lamellar or Laminar Calcification

 Terbentuk di dalam
lumen
 Batu ginjal
 Batu empedu
 Batu buli
Cloudlike, Amorphous, Popcorn like
calcification
 Terdapat pada organ
padat atau tumor:
 Leiomyoma uterus
 Cystadenoma ovarium
 Nefrokalsinosis
 Kista dermoid
(kalsifikasi berbentuk
gigi)
 Kalsifikasi pankreas
 Kalsifikasi prostat
Cloudlike, Amorphous, Popcorn like
calcification
 Terdapat pada organ
padat atau tumor:
 Leiomyoma uterus
 Cystadenoma ovarium
 Nefrokalsinosis
 Kista dermoid
(kalsifikasi berbentuk
gigi)
 Kalsifikasi pankreas
 Kalsifikasi prostat
KASUS-KASUS
LATIHAN
KASUS 1
 Pasien seorang laki-laki
dewasa, post kolostomi ai
tumor kolon, datang ke UGD
dengan keluhan nyeri perut
dan perut makin membuncit.

 Pemeriksaan apa yang telah


dilakukan dan posisi-posisi foto ?
 Apa penemuan radiologisnya ?
 Apa kemungkinan diagnosisnya ?
Mechanical small bowel
obstruction

 small bowel dilatation


 thickening of bowel wall
 herring bone
appearance
plain abdominal x-ray  colon gas (-)
plain abdominal x-ray
3 position
 Mechanical bowel obstruction

AP-semi
recumbent,
horizontal ray

AP-supine, vertical ray


LLD, horizontal ray
plain abdominal x-ray

stack of coin
apabila satukolomusus
Coiled dilatasi
halusyang spring

herring-bone appearance

terbentuk akibat 2 usus halus yang


dilatasi dan berdekatan
Laki-laki, 25 thn,
keluhan nyeri
abdomen dan perut
tegang
Laki-laki, 35 thn, keluhan
nyeri abdomen, tdk bisa
flatus dan perut tegang

• Apa yang ditemukan


pada foto polos abdomen
?
• Apa diagnosisnya ?
• Apa saran pemeriksaan
lain ?

Obstruksi mekanik usus besar.


Inkompeten katup ileosekal.
Lanjutan …..

Obstruksi mekanik usus besar. Inkompeten katup ileosekal.


Imajing Obstruksi Usus Halus (SBO):

• Radiografi konvensional  first choice


 Dilatasi loop-loop usus di bagian proksimal dari obstruksi
 diameter > 2,5-3 cm.
 Tinggi rendah air-fluid level pada loop yang sama tidak
satu level  membentuk step-ladder
 Tidak adanya udara di usus besar atau tidak
proporsionalnya jumlah udara di rektosigmoid dengan
udara si usus halus.
 Bebepara loop usus yang penuh dengan cairan dapat
menunjukkan tanda string of beads atau string of pearls
yang disebabkan oleh terparangkapnya sejumlah kecil
udara di valvula conniventes usus halus.
SBO (continue…)
• CT scan  dapat menunjukkan lokasi dan penyebab dari
obstruksi
 Dilatasi usus di proksimal dari obstruksi dan kolaps di bagian
distalnya
 Small bowel feces sign terjadi karena tercampurnya udara dan
material isi usus yang stasis di lokasi obstruksi, sehingga menyerupai
gambaran feses
 Adhesi bisanya tidak terlihat, tetapi adanya perubahan mendadak
kaliber usus tanpa penyebab yang jelas (seperti tumor) merupakan
suatu petunjuk adanya perlekatan.
 Tanda adanya strangulasi : penebalan dinding usus, peningkatan
atenuasi, keterlibatan (stranding) dari mesenterium disekitarnya atau
adanya pneumatosis intestinalis
 CT scan dapat memperlihatkan adanya tumors, Crohn’s disease,
gallstone ileus, hernias, closed loop obstructions yang tidak
terdeteksi dengan radiografi konvensional.
DD/.
Ileus obstruktif vs Ileus paralitik

Differentiating SBO from Paralytic Ileus


SBO Ileus Paralytic

Patient with prior surgery Recent (hours) post-


Etiology
weeks to years prior operative patient

Pain Colicky Not a prominent feature


Abdominal distension Frequently prominent Sometimes not apparent
Bowel sounds Usually increased Usually absent
Small bowel dilatation Present Present
Large bowel dilatation Absent Present
Laki-laki, 75 thn. Nyeri perut dan sulit BAB.

Fecal mass prominen.


Meteorismus dan skibala.
KASUS 2
Wanita, 55 thn,
keluhan nyeri
abdomen, dinding
perut tegang

• Apa yang ditemukan


pada foto polos
abdomen ?
• Apa diagnosisnya ?
• Apa saran
pemeriksaan lain ?
Sigmoid volvulus
Large, dilated loop of large bowel The same patient with decompressed
with an inverted U-shape sigmoid volvulus following insertion of
with walls between two volvulated rectal tube
loops pointing from LLQ toward
RUQ
Imaging
• Biasanya foto polos abdomen sudah dapat mendiagnostik.
 Inverted U-shaped  distensi fokal usus
 Dilatasi fokal yang sangat besar dari loops usus  volvulus
 Hilangnya gambaran haustra
 Coffee-bean sign.
 Sigmoid volvulus – bowel loop points to RUQ
 Cecal volvulus – bowel loop points to LUQ
 Bird’s-beak or bird-of-prey sign : terlihat pada barium enema
• CT scan  iskemik dinding usus
Cecal volvulus  Sigmoid volvulus 
bowel loop points to LUQ bowel loop points
to RUQ
KASUS 3
Laki-laki, 50 thn,
keluhan nyeri
abdomen, BAB
berdarah

• Apa yang ditemukan


pada foto polos
abdomen ?
• Apa diagnosisnya ?
• Apa saran
pemeriksaan lain ?
Pemeriksaan Barium
enema pasien tersebut.

• Pemeriksaan apa ini?


• Apa yang ditemukan ?
• Apa diagnosisnya ?

Intususepsi ileosekal. Barium enema  Coiled spring appearance


Tipe invaginasi
USG :
invaginasi-cross
sectional

Target sign
KASUS 4
Laki-laki dewasa,
keluhan nyeri
abdomen, febris

Appendicolith

• Apa yang ditemukan
pada foto polos
abdomen ?
• Apa diagnosisnya ?
• Apa saran
pemeriksaan lain ?
Acute appendicitis

Etiology
• Obstruction of appendiceal lumen by :
 Lymphoid hyperplasia
 Fecolith
 Foreign bodies
 Stricture
 Tumor
 Parasite
 Crohn’s disease
Clinical findings
• RLQ pain over appendix is a positive McBurney sign
• Leukocytosis
• Fever
• Nausea and vomiting
• Relatively higher rate of misdiagnosis in women between
ages 20-40
 May have an atypical location
Imaging Findings
• Abdominal plain film (abnormalities seen in <50%)
 Foto polos abdomen akan lebih spesifik setelah
appendiks perforasi, apabila gejala klinis tidak khas.
 Kalsifikasi (appendicolith )  di RLQ
 Appendicolith dan nyeri abdominal = 90% acute
appendicitis
 "Cecal ileus" = local paralysis
 Small bowel obstruction pattern
 Soft-tissue mass dan kesuraman atau udara di
abdomen kanan bawah tidak ada (mungkin disertai
perforasi).
 Pneumoperitoneum yang jelas sangat jarang terjadi,
karena lumen apendiks buntu terhadap usus dan lumen
apendiks relatif kecil
 Penebalan fokal dinding abdomen lateral kanan
 Hilangnya properitoneal fat line di sisi kanan
 Skoliosis lumbar ke kiri.
Abdomen plain
film

appendicolith

Scoliosis lumbal
• US (77-94% sensitive, 90% specific, 78-96% accurate)
 Useful in ovulating women (false-negative appendectomy
rate in males 15%, in females 35%):
 Visualization of noncompressible appendix as a blind-
ending tubular aperistaltic structure (seen only in 2% of
normal adults, but in 50% of normal children)
 Target sign, appearance of >6 mm in total diameter on
cross section (81%)
 Mural wall thickness >2 mm
 Diffuse hypoechogenicity (associated with higher
frequency of perforation)
 Lumen may be distended with anechoic / hyperechoic
material
 Loss of wall layers
 Visualization of appendicolith (6%)
 Localized periappendiceal fluid collection
 Prominent hyperechoic mesoappendix / pericecal fat
appendicolith

Inflammed appendix distended appendix lumen


Sausage sign Target sign

Color Doppler US:


 Increase of vessels in and around the appendix
• Color Doppler US:
 Increased conspicuity from increase (in size + number) of
vessel) s in and around the appendix
 Decreased resistance of arterial waveforms
 Continuous / pulsatile venous flow

• BE / UGI (accuracy 50-84%):


 Failure to fill appendix with barium (normal finding in up
to 35%)  Non-filling appendix
 Indentation along medial wall of cecum (from edema at
base of appendix / matted omentum / periappendiceal
abscess)
• Appendicogram  ??
• CT (87-98% sensitive, 83-97% specific, 93% accurate)
Distended lumen
 Circumferentially thickened and enhancing wall
 Appendicolith = homogeneous / ringlike calcification
(25%)
 Periappendicular inflammation-linear streaky
densities in periappendicular fat
 Pericecal soft-tissue mass
 Abscess
 Poorly encapsulated
 Single or multiple fluid collection(s) with air
 Extraluminal contrast material
 Focal cecal wall thickening (80%)
 "Arrowhead" sign = funnel of contrast medium in
cecum centering about occluded orifice of appendix
Appendicolith and appendix
with thickened and enhancing
wall .

peri-appendiceal stranding.
Complications
• Perforation (13-30%)

Differential diagnosis (DDx) :


• Colitis
• Diverticulitis
• Epiploic appendagitis
• Infectious enteritis
• Intussusception
• Crohn’s disease
• Mesenteric lymphadenitis
• Ovarian torsion
• Pelvic inflammatory disease
KASUS 5
Wanita, 65 thn, keluhan
nyeri abdomen kanan
atas, perut menegang

• Apa yang ditemukan


pada foto polos
abdomen ?
• Apa diagnosisnya ?
• Apa saran
pemeriksaan lain ?
Gallstone ileus

• Pneumobillier.

• Obstruksi usus halus

• Sulit menentukan
lokasi obstruksi.
Gallstone ileus
Gallstone
Gallstone ileus
KASUS 6
42 year-old male with acute abdominal pain

Plain abdominal photo


Acute pancreatitis.

Plain abdominal photo

Pancreas calcification

Colon cut off sign


CT scan pasien tersebut
Acute pancreatitis.

Acute pancreatitis.
The pancreas is enlarged (blue arrow) with indistinct and shaggy margins.
There is peripancreatic fluid (red arrow) and extensive peripancreatic
infiltration of the surrounding fat (black arrow).
Acute pancreatitis.

USG Contrast Enhance CT


Acute Pancreatitis

Causes

• Gallstones
• Alcohol abuse, usually chronic
• ERCP-induced
• Trauma, more often penetrating
• Drug-induced
• Infectious, especially post-viral in children
• Vasculitis
• Idiopathic
Clinical findings

• Sudden onset of dull, boring epigastric pain which classically


radiates to the back
• Nausea
• Vomiting
• Symptoms frequently begin after heavy drinking or large
meal
• Laboratory findings include an elevated serum amylase and
lipase levels
Imaging findings

• Study of choice is contrast-enhanced CT


• Contrast is best for establishing presence of
pancreatic necrosis
• Pancreas may appear normal in 25% of patients
with mild pancreatitis

• Conventional radiography
• May show colon cut-off sign of air in dilated
transverse colon to the splenic flexure
• Localized ileus in left upper quadrant
• May show a paucity of gas from fluid-filled bowel
• Left pleural effusion
• CT
• Focal or diffuse enlargement of the pancreas
• Heterogeneous enhancement
• Indistinct or shaggy margins
• Infiltration of the peripancreatic fat
• Fluid collections in the peripancreatic and anterior
pararenal spaces
• MRI
• Used primarily in patients in whom iodinated contrast
is contraindicated
• About equal to CT in diagnostic accuracy
• US
• Ultrasound is used primarily for follow-up of
pseudocysts or establishing presence of gallstones
• May be helpful in diagnosing a pseudoaneurysm or
venous thrombosis
Complications
• Fluid collections
• Peripancreatic and anterior pararenal space most commonly
• Pseudocyst formation
• Collection of pancreatic juice enclosed by a wall of fibrous or
granulation tissue
• Often communicates with the pancreatic duct
• Typically takes about 4 weeks to develop from the onset of
clinical symptoms
• Pseudocysts classically appear on CT as a water-density
collection with a defined wall which may contrast-enhance
• Abscess
• A circumscribed intra-abdominal collection of pus
• Typically takes about 4 weeks to develop from the onset of
clinical symptoms
• May produce a thick-walled fluid collection with gas bubbles
or an area of poorly defined fluid with heterogeneous
attenuation
• Confirmation of diagnosis may require aspiration of pus
• Pancreatic necrosis
• Focal or diffuse areas of nonviable pancreatic parenchyma,
which usually is associated with peripancreatic fat necrosis
• Necrosis typically develops early in course of acute
pancreatitis
• Fails to enhance on CT with IV contrast (>3 cm in size)
 Normal, unenhanced pancreas= 30-50 Hu
 Normal enhanced pancreas=100-150 Hu
• Necrosis and abscess may be indistinguishable
• Hemorrhage
• High-attenuation fluid collections
• Venous thrombosis
• Recognized by failure of the peripancreatic veins such as the
splenic vein or portal vein to enhance or by the presence of an
intraluminal filling defect
• Pseudoaneurysm formation
• Well-defined contrast-containing rounded structure
Treatment
• Mild pancreatitis is treated medically with IV fluids
and analgesics
• In severe cases, treatment may include aggressive
fluid therapy, antibiotics and tube feedings
• CT and US can be used for guidance in aspiration of
pseudocysts and suspected pancreatic abscesses
• Non-infected pseudocysts resolve spontaneously in
about 50% of cases
• Pancreatic necrosis usually requires surgical
intervention whereas pancreatic abscesses can be
percutaneously drained
Prognosis
• Overall mortality rate for patients with acute
pancreatitis is 10-15%
 With severe disease, rate goes up to 30%
KASUS 7
Keluhan pasien:
Perut membuncit dan
sesak napas.

Dilakukan radiografi
polos abdomen, hasil
sbb :
Ascites, supine abdomen.
• central displacement of the loops of bowel,
• an uniform grayness to the abdomen,
• loss of any definition of the edge of the spleen or liver
• displacement of the bowel loops out of the pelvis
CT scan sangat baik
untuk mendeteksi asites
walaupun jumlah cairan
sangat sedikit.
USG sangat baik untuk mendeteksi asites

Efusi pleura dan asites

Cairan bebas diantara usus-usus 


Imaging Findings
Conventional radiographs On CT
 Uniform grayness to abdomen  Sparing of the “bare” area of the
 Central placement of bowel posterior aspect of the right lobe
loops of the liver which is not covered
 Separation of adjacent loops by peritoneum
 Loss of definition of the liver  Fluid that lies posterior to the
and/or spleen edge liver at this point is pleural
 Bladder-ears ─ fluid collects in effusion, not ascites
pelvis on either side of bladder in  Ascitic fluid lies anterior to the
peritoneal space diaphragm on axial sections,
 Thickening of peritoneal flank pleural fluid is posterior
stripe
 Medial displacement of
ascending and descending colon
 Bulging flanks Ascites

PE
KASUS 8
Wanita, 45 thn,
keluhan nyeri
abdomen

• Bgmn posisi foto ini?


• Apa yang ditemukan
pada foto polos
abdomen ?
• Apa diagnosisnya ?
• Apa saran
pemeriksaan lain ?
Pneumoperitoneum.
Foto abdomen posisi supine:
• Terlihat udara berbentuk
bulan sabit (crescent sign)
dibawah diafragma kanan-
kiri
• Udara di luar dan di dalam
lumen usus yang
menyebabkan dinding usus
terlihat dengan jelas
(Rigler’s sign)
• Tampak pula gambaran
lusen disekeliling hepar
yang disebabkan oleh
udara bebas yang cukup
banyak.
Wanita, 45 thn, keluhan nyeri abdomen

• Bgmn posisi foto ini?


• Apa yang ditemukan
pada foto polos
abdomen ?
• Apa diagnosisnya ?
• Apa saran
pemeriksaan lain ?
Imaging : Radiografi polos :
• Terlihat jelas pada posisi sinar X horizontal
 CXR berdiri termasuk diaphragm, atau
 AXR berdiri termasuk diafragma, atau
 Left lateral decubitus (LLD) abdomen
 Pasien tidur pada tubuh sisi kiri, (sisi kanan diatas)
 Udara terlihat diatas hepar
• Udara di kwadran kanan atas (dapat terlihat udara
minimal)
 Gambaran hiperlusensi diatas hepar
 Gambaran hiperlusen di tepi hepar posteroinferior
 Area segitiga (triangular )  udara terperangkap dibawah
tendon diafragma.
Imaging findings
• Three major findings
 Free air beneath diaphragm (crescent sign)
 Visualization of both sides of the bowel wall
 "Rigler’s sign"
 Normally, only the inside of the bowel (the
lumen) is visible unless free air outlines the outer
surface of the wall
 Visualization of the falciform ligament
 Long vertical line to the right of midline extending
from ligamentum teres notch to umbilicus; most
common structure outlined
 "Football sign" = large pneumoperitoneum outlining
entire abdominal cavity with “laces” representing
falciform ligament (most common in children).
falciform ligament

Football sign
Cupola sign

Bayangan radiolusen berbentuk kubah dengan tepi atas


batas tegas dan batas bawah kabur
Rigler’s sign :
dinding usus terlihat jelas karena ada udara intra
dan ekstralumen
Football sign

Bentuk oval di rongga


peritoneum dengan
ligamentum falciformis
sebagai pembagi.
Pneumoperitoneum

CT scan

 Sensitifitas dan spesifisitas CT scan


sangat tinggi untuk mendeteksi
udara bebas dalam jumlah sedikit
KASUS 9
Laki-laki, 45 thn,
keluhan benjolan dan
nyeri abdomen

• Apa yang ditemukan


pada foto polos
abdomen ?
• Apa diagnosisnya ?
• Apa saran
pemeriksaan lain ?
Plain abdominal x-ray
shows soft tissue
mass in pelvic and
lower abdominal
cavity.

Myoma Uteri MRI


KASUS 10
Gastric Volvulus

 Stomach twists on itself


 Etiologies :
 Abnormality of the suspensory
ligaments of the stomach:
o Gastrohepatic
o Gastrosplenic
o Gastrocolic
o Gastrophrenic
 Unusually long gastrocolic and gastrohepatic
mesentery
 Classified as one of two types  organoaxial or
mesenteroaxial
Gastric Volvulus Types

Type Appearance Description Remarks

•  Most common
• Twist occurs along type.
a line connecting •  Usually associated
the cardia and the with diaphragmatic
Organoaxial pylorus--the defects.
luminal (long) axis •  Vascular
of the stomach compromise more
common.

• Twist occurs
around a plane •  Chronic symptoms
perpendicular to more common.
Mesenteroaxial the luminal (long) •  Diaphragmatic
axis of the stomach defects less
from lesser to common.
greater curvature
 Clinical findings .
 Unless acute, patients are frequently asymptomatic .
 When acute and obstructing:
o Abdominal pain
o Attempts to vomit without results
o Inability to pass an NG tube
o Together, these three findings comprise the Borchardt triad which is
diagnostic of acute volvulus
• Reportedly occurs in 70% of cases
 Imaging findings
 Massively dilated stomach in LUQ possibly extending into
chest
 Inability of barium to pass into stomach (when obstructed)
Organoaxial
Gastric Volvulus
Organoaxial
Gastric Vulvulus

Kurvatura mayor berada di kranial


dari kurvatura minor
Mesenteroaxial
Gastric Vulvulus
Mesenteroaxial
Gastric Vulvulus

Esophago-gastric junction letaknya


berdekatan dengan pilorus gaster.
Clinical finding : Newborn vomitus

Plain abdominal photo :


• Dilated of stomach and
duodenum
• Gas free of intestines

• Double bubble sign

Duodenal atresia
Hirschsprung dss:
Six (6) months old boy,
fecal retention in
rectum and dilatation of
proximal bowel.
plain abdominal x-ray

Mechanical small bowel


obstruction

 small bowel dilatation


 thickening of bowel wall
 herring bone
appearance
 colon gas (-)
plain abdominal x-ray
3 position
AP-semi
 Mechanical bowel obstruction recumbent,
horizontal ray

AP-supine, vertical ray


LLD, horizontal ray
plain abdominal x-ray

Ileus : herring-bone appearance


plain abdominal x-ray,
lateral position – horizontal ray

External hernia
plain abdominal x-ray

radio opaque stone soft tissue mass


Mechanical large bowel obstruction

Colon dilatation

obstruction.

Barium enema
volvulus of sigmoid colon
Post operation complication :
Metallic clamp is found intrabdominal
Plain abdominal x-ray

air in portal vein

NEC
= necrotizing
entero-colitis

pneumatosis intestinalis
Hirschsprung dss:
Six (6) months old boy,
fecal retention in
rectum and dilatation of
proximal bowel.
RADIOLOGI GASTROINTESTINAL :

KONVENSIONAL
DENGAN KONTRAS
1. Oral cavity : Salivary glands

Parotid gland  Stenson’s duct  M2/M2


Submandibular gland  Wharton’s duct
Submental gland

Radiology modality :
 Plain photo
 Sialography
 USG
 CT Scan
 MRI
Sialography
Normal sialography
Sialography : used water soluble
contrast

Plain photo.
Stone in submandibular duct.

Globular sialectasis of parotid gland

From David Sutton. Textbook of Radiology and Medical Imaging


Sjogren‘s syndrome
Sjogren‘s syndrome is a disorder of
immune system identified by its two
most common symptoms  dry
eyes and a dry mouth.
Sjogren's syndrome often accompanies
other immune system disorders,
such as rheumatoid arthritis and
lupus.
In Sjogren's syndrome, the mucous
membranes and moisture-secreting
glands of eyes and mouth are
usually affected first — resulting in
decreased production of tears and
saliva.
MRI :
Parotid tumor : pleomorphic
adenoma.

CT scan :
Parotid tumor : adenocarcinoma.

From David Sutton. Textbook of Radiology and Medical Imaging


2. Oesophagus, Stomach, Duodenum

Radiology modality :
 Plain photo
 Barium swallow  esophagography
 Barium meal  OMD = Esophagus, Maag, Duodenum
 EUS = endoscopic ultrasonography
 CT scan
 MRI
 Nuclear medicine
 Interventional radiology
Anatomy : Stomach

Radiographic anatomy
Barium meal :
Patient preparation :
 Fasting at least 8 hours
 Abstain from smoking
 Women : pregnant ?

Radiographic equipment :
• Conventional fluoroscopy
• Remote-control fluoroscopy
• Cine-radiography and video-fluorography
Radiographic technique :

• Single contrast barium meal


– Barium suspension only
– Observation of peristaltic and well demonstrated of
fistulae and obstruction

• Double contrast barium meal


– Barium suspension and distention by gas producing
agent
– Demonstrate : fine mucosal detail
– Operator skill and experienced is important
Radiographic of
Normal Esophagus, Stomach and Duodenum
Diffuse esophageal spasm:
corkscrew esophagus
Mangosteen (foreign body)
intralumen of oesophagus

Intralumen filling defect Pasien riwayat tersedak saat makan


buah manggis.
Foreign body  Mimicking tumor
Tumor : Gastric wall filling
defect

Gastric carcinoma
Lenities plastica
Additional shadow

Duodenum diverticle Multiple diverticulosis


3. Small Intestines

Barium follow through (SC)

Enteroclysis (DC)
RADIOLOGY ANATOMY of
Stomach, Jejunum and
Ileum Ileum
Ileum

Stomach,

Jejunum
Barium Follow Through

 Patient fasting
 Single contrast : 200 – 500 cc of barium
suspension is given to drink
 Followed by fluoroscopic or conventional x-ray.
 Taken serial photo : 5‘ , 10’, 20’ etc.
 Examination must be stop when barium filling
the caecum.
Enteroclysis
(=small bowel enema)

 Inserted the NGT (12F Bilbao-Dotter tube


135 cm long).
 Maneuver catheter tip to the anthrum 
passing pylorus  placed and fixation
catheter tip in duodenal 3rd parts.
 Contrast irrigation + (methylcellulose or air
insufflating)  Double contras method
 Filming
Enteroclysis - normal small
bowel mucosa

follow through : normal


small bowel
Small intestine cases

Ascaris in small bowel


The worm ingests
barium and the
barium may be seen
as a thin line of
contrast in the
center of the worm,
especially after the
remainder of the
barium exits the
small bowel.
4. Large Intestine = colon

Radiology modality :
 Plain abdominal radiographs
 Barium enema = colon in loop
Plain abdominal x-ray

Technique :

 AP – Supine
 AP – Erect
 LLD
 Semi recumbent
 CXR

Indication :
• Acute abdomen
Barium Enema

= Colon in Loop
The routine examination of the colon

Technique :
• Single Contrast : barium suspension
• Double Contrast : barium susp.+ gas
Radiology Anatomy

Caecum - colon - rectum


Indication

Single contrast barium enema :


 Intussusceptions
 Diverticle dss/diverticulosis/diverticulitis
 Colonic polyps
 Colon and rectal carcinoma
 Crohn’s dss
 Hirschprungs dss
 Fatique / very old patient / serious illness
 Suspected pelvic metastasis
Indication

Double contrast barium enema :


• Melena / bloody stool
• Chronic diarrhea
• Pain & abdominal discomfort
• IBD (inflamatory bowel dss)
• Diverticulosis
• Suspected colonic carcinoma
• Suspected colonic polyp / familial polyposis
• Family history of colonic ca / polyp
Contraindication

• Suspected bowel perforation


• Toxic megacolon
• After colonic biopsi
• After snare polypectomy
Complication

• Gas pain
• Colonic perforation or colonic ruptur
• Water intoxication
• Colonic intramural barium
• Rectal laserasion
• Bactery contamination
• Allergy / hipersensitivitas of barium or
glukagon/buscopan
Preparation

Patient preparation

 Low residue diet


 Increased fluid intake
 Rectal or oral laxative (if needed)
 Antispasmodic agent :
1. Glucagons : intravenous : 0,5 – 1 mg.
2. Buscopan (hyoscine N-butylbromide) : iv or
im : 1 ampul (20 mg/mL)
Contrast preparation

Barium sulphate suspension :


• Single contrast : 12% - 25% w/v
• Double contrast : 70% - 100 % w/v
Conventional digital fluoroscopy
Remote-control fluoroscopy
4
Irigator preparation 1

Plastic irigator :
1. enema tip
2. enema tube
3. enema reservoir bag
4. retention balloon with its 3
inflator.

2
1
4
4
2
Technique & positioning

A.
Left lateral position :
contrast filling
rectum and
rectosigmoid

B.
Left posterior
oblique (LPO):
contrast filling
sigmoid
C.
Left lateral with 15o
Trendelenberg position :
contrast flow to descendent
colon and lienalis flexure

D.
Clockwise to prone position:
contrast filling transversal
colon
E.
Clockwise to right lateral
with 15o Trendelenberg
position : contrast filling the
hepatic flexure

F.
From E, turn left to supine
position : contrast filling
hepatic flexure and
ascendant colon
G.
Turn to left posterior oblique
(LPO) to filling the
ascendants colon

H.
From G position, turn
clockwise to supine
position: contrast filling the
caecum
Recording / filming

• Plain abdominal photo


• Spot photo
• Overhead whole abdomen

Plain abdominal photo


Barium
Enema
Single
Contrast
Spot film : Single contrast

Rectum (left lateral) Sigmoid Lienalis flexure

Hepatic flexure Caecum


Whole abdomen : single contrast

Whole colon :
 overhead film

Overhead film
Barium
Enema
Double
Contrast
Spot film : double contrast

Rectum & sigmoid :

Lateral position Supine position Prone position


Spot film : double contrast

Distal descendant colon Proximal


Sigmoid :
descendant colon
posterior oblique
Spot film : double contrast

Lienalis flexure Transverse colon


(RPO)
Erect position
Spot film : double contrast
Ascendant colon
Hepatic flexure

Erect position Erect position, LPO


Spot film : double contrast
Caecum & appendix caecum & terminal ileum
Overhead film :
whole colon
Others position (if needed)

Right lateral decubitus (RLD)

- Redundant colon
- Decubitus to right side
(RLD)
- Horizontal ray
- Clearly evaluated :
lateral of descendant
and medial of
ascendant colon
Others position (if needed)

Left lateral decubitus (LLD)

- Redundant colon
• Decubitus to left side
- Horizontal beam
• Clearly evaluated : lateral of
ascendant and medial of
descendant colon
Single contrast vs Double contrast

SC DC

 Motility study (++). • Motility (+/-).


 Bowel contour (++), • Contour and mucosa
mucosa (-) (++)
 Simple technique. • Difficult technique
False-positive findings :

1. Residual stool  may mimic a tumor.


2. The ileocecal valve  may mimic a cecal
tumor.
3. A submucosal mass (such as a lipoma or
benign mucosal adenoma)  may be
indistinguishable from a small polypoid
cancer.
4. Diverticulitis  Strictures and paracolic
collections may mimic a neoplasm.
false-positive findings :

5. Extrinsic compression of the colon by an


adjacent tumor may mimic a primary colonic
tumor.
6. Strictures: Inflammatory bowel disease,
ischemic colitis, radiation colitis, and
tuberculous colitis may mimic a malignant
strictures.
False-negative findings :

1. Inadequate bowel preparation: Residual


stool may obscure a carcinoma.
2. Diverticulosis: severe sigmoid diverticulosis
 missed cancers is increased.
3. Small lesions: may be missed in a dense
pool of barium.
4. Errors of perception: can be reduced by a
second reading performed by a different
observer.
Polyp

Bubble 
Pedunculated Polyp

Sessile Polyp

En profile view

En face view

En profile view

Mexican hat sign “sombrero”


Malignant polyp : villous type
• Apple core sign
• Shoulder sign

Carcinoma colon : annular


type
Colonic diverticulitis

Colonic diverticulosis
Multiple additional shadow
IBD : ulcerative colitis

Continuous ascendering lesion

Segmental colitis Pancolitis


IBD: Colitis Crohn’s

• Discontinuous lesion of the


bowel,
• Skip lesion sign.
Colitis TB

Caecum 

 Terminal ileum

Rectal Ca.
• Barium enema lateral view.
• The lumen of the rectum is narrowed
severely by the circumferential mass
with mucosal destruction and the
overhanging edges or shouldering at the
tumor margins.
Colonic polyp
Filling defect on single contrast Soft tissue mass on double contrast
Extraluminal tumor

Ba enema : ileocaecal intussusceptions


(Coiled spring appearance)
Secondary tumor.

Metastases from breast


carcinoma