GASTROINTESTINAL:
FOTO
KONVENSIONAL
Udara usus
Udara ekstralumen
Massa jaringan
lunak
Kalsifikasi
Udara 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 ?
Functional Ileus :
Localized ileus (Sentinel Loops)
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
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
supine erect
Generalized Ileus (Ileus paralitik)
Yaitu:
Udara bebas intraperitoneal
Pneumoperitoneum
Tanda perforasi hollow viscus.
Hepatosplenomegaly
(Ctt: mengukur hepar
pd foto polos tidak
tepat).
Tumor padat atau
kista
Pendorongan udara
usus
Tampak kesuraman
Kompresi ekstrinsik
udara usus
Hours later
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.
AP-semi
recumbent,
horizontal ray
stack of coin
apabila satukolomusus
Coiled dilatasi
halusyang spring
herring-bone appearance
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
peri-appendiceal stranding.
Complications
• Perforation (13-30%)
• Pneumobillier.
• Sulit menentukan
lokasi obstruksi.
Gallstone ileus
Gallstone
Gallstone ileus
KASUS 6
42 year-old male with acute abdominal pain
Pancreas calcification
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.
Causes
• Gallstones
• Alcohol abuse, usually chronic
• ERCP-induced
• Trauma, more often penetrating
• Drug-induced
• Infectious, especially post-viral in children
• Vasculitis
• Idiopathic
Clinical findings
• 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
PE
KASUS 8
Wanita, 45 thn,
keluhan nyeri
abdomen
Football sign
Cupola sign
CT scan
• 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
Duodenal atresia
Hirschsprung dss:
Six (6) months old boy,
fecal retention in
rectum and dilatation of
proximal bowel.
plain abdominal x-ray
External hernia
plain abdominal x-ray
Colon dilatation
obstruction.
Barium enema
volvulus of sigmoid colon
Post operation complication :
Metallic clamp is found intrabdominal
Plain abdominal x-ray
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
Radiology modality :
Plain photo
Sialography
USG
CT Scan
MRI
Sialography
Normal sialography
Sialography : used water soluble
contrast
Plain photo.
Stone in submandibular duct.
CT scan :
Parotid tumor : adenocarcinoma.
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 :
Gastric carcinoma
Lenities plastica
Additional shadow
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)
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
• 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
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
Whole colon :
overhead film
Overhead film
Barium
Enema
Double
Contrast
Spot film : double contrast
- Redundant colon
- Decubitus to right side
(RLD)
- Horizontal ray
- Clearly evaluated :
lateral of descendant
and medial of
ascendant colon
Others position (if needed)
- 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
Bubble
Pedunculated Polyp
Sessile Polyp
En profile view
En face view
En profile view
Colonic diverticulosis
Multiple additional shadow
IBD : ulcerative colitis
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