ABDOMINAL AND

GASTROINTESTINAL TRACT
IMAGING

Dr. Mahmoud Alkhasawneh

Mu’tah University
 ABDOMEN X-RAY

✔ Plain abdomen films still retain one of the most useful initial
investigations.
✔ Abdomen x-ray is sometimes abbreviated to AXR and is
usually taken with the patient lying in a supine position.
✔ In an erect abdomen x-ray, normally two or three air-fluid
levels are possible, but more than three are abnormal.
✔ The maximum diameter of the small bowel is 3cm.
✔ The maximum diameter of the large bowel is 6cm, except for
the caecum and rectum up to 8cm.
NORMAL ABDOMINAL X RAY
ABDOMEN X-RAY / 2

o The following structures should be checked in

abdomen x-ray:
❖ Bowel gas pattern.
❖ Radio-opaque stones or calcification.
❖ Extra luminal free gas. wilms tumor ( kidny )
aortic anyorism
❖ Soft tissue masses. hydated cyst
❖ Signs of intestinal obstruction. ovarian tumor
❖ Skeletal abnormalities.
 REMEMBER :

1. Radiopaque (white) :Stone , Fluid.

2. Radiolucent (black) : Gas .
3. X-ray is not enough, you must consider the clinical
presentation and physical examination.
 Extraluminal gas

Liver

Lumbar spine

Gases in cecum
 RUQ
Abdominal Xray

Normal gas distribution

Stones
Opaque Lumbar
Calcification
1 cm
In lumbar

DDX ::
Kidney stone
Not definitely (2D)

RIF
Age :2 days
With vomiting
Problem in gas stomach

No masses

No stones

Dudenal atresia
ACUTE APPENDICITIS
• Acute appendicitis is an acute inflammation of the
Appendix.
• The vermiform appendix is a tubular structure
attached to the base of the caecum. It is
approximately 5-10 cm long in adults .
• Appendicitis happens when the appendix gets
blocked .
• Appendicitis is the most common abdominal
emergency and accounts for more than 40 000
hospital admissions in England every year
CLINICAL PRESENTATION

• The classical presentation consists of periumbilical

pain (referred) which within a day or later localizes to
McBurney point with associated fever, nausea, and
vomiting.
• Children are often present with vague and non-
specific signs and symptoms.
• Deep tenderness at McBurney's point, known as
McBurney's sign
IMAGING

One of the biggest challenges of imaging the appendix is

finding it.
• Plain Films of the Abdomen

• Plain Films of the Abdomen are UNABLE to give the diagnosis,

however, are useful for identifying FREE GAS, and may show
an APPENDICOLITH in 7-15% of cases. Finding an
appendicolith makes the possibility of acute appendicitis up
to 90%.

• Small Bowel Obstruction pattern with small bowel dilatation

and air-fluid levels is present in ~40% of perforations.
Appendicolith
 ACUTE APPENDICITIS IN ULTRASOUND
Ultrasound with its lack of ionizing radiation should be
the investigation of choice in young thin patients.

Findings supportive of the diagnosis of appendicitis include :

• Aperistaltic, blind-ending non-compressible, dilated appendix
(>6 mm outer diameter).
• Hyperechoic appendicolith with posterior acoustic shadowing.
• Echogenic prominent pericaecal and periappendiceal fat.
• Periappendiceal fluid collection.
• target appearance (axial section).
• wall thickening (3 mm or above). fluidgas ,
 ACUTE APPENDICITIS IN ULTRASOUND
Tube like structure

Echogenich fat ‫حواليها‬

Black:: fluid ‫حواليها‬

Target sign
CT SCAN Highly sensitive

• CT is highly sensitive (94-98%) and

specific (up to 97%) for the diagnosis
of acute appendicitis and allows for
alternative causes of abdominal pain
also to be diagnosed.
CT FINDINGS INCLUDE :

• appendiceal dilatation (>6 mm diameter)

• wall thickening (>3 mm) and enhancement
• thickening of the cecal apex: cecal bar sign.
• periappendiceal inflammation
• fat stranding
• extra luminal fluid
• phlegmon (inflammatory mass)
• Abscess

• Less specific signs may be associated with appendicitis:

• appendicolith
• periappendiceal reactive nodal enlargement
RECOGNIZED COMPLICATIONS INCLUDE :

perforation: in 10-20% of cases

most specifically suggested by appendiceal abscess or extraluminal gas, but
commonly also seen as periappendiceal phlegmon and fluid
generalized peritonitis due to free perforation
pylephlebitis: infective thrombophlebitis of the portal circulation
hepatic abscess

When a complication occurs, it is said to be "complicated appendicitis".

SUMMARY POINTS

• Appendicitis is the most common abdominal surgical

emergency
• Not all patients present with typical signs and symptoms
• Patients at the extremes of age have increased mortality
because of late presentation or subtle signs
• Specialist investigations should not delay definitive treatment
• Computed tomography scanning is more sensitive and specific
than ultrasonography when diagnosing acute appendicitis
SMALL BOWEL OBSTRUCTION

• Small bowel obstruction is a partial or complete

blockage of the small intestine.
• An obstruction in the small bowel can partly or
completely block contents from passing through.
• Gas and fluid accumulate proximal to the site of
obstruction causing progressive dilatation of the small
bowel.
 Stop
THERE ARE TWO TYPES OF SMALL BOWEL OBSTRUCTION:

• functional — there is no physical blockage, however,

the bowels are not moving food through the digestive
tract

• mechanical — there is a blockage preventing the

movement of food.
WHAT CAUSES SMALL BOWEL OBSTRUCTION?
Functional SBO :
• Bacteria or viruses that cause intestinal infections
(gastroenteritis)
• Chemical, electrolyte, or mineral imbalances (such as
decreased potassium level)
• Abdominal surgery
• Decreased blood supply to the intestines (Mesenteric
ischemia)
• Infections inside the abdomen, such as appendicitis
• Kidney or lung disease
• Use of certain medicines, especially narcotics
MECHANICAL SBO
• Adhesions: is the most common cause, about 70% of
cases. These are bands of scar tissue that may form after
abdominal or pelvic surgery.
• Hernias : Hernias are the second most common cause of
small bowel obstruction in the United States.
• Inflammatory disease: Inflammatory bowel disorders such
as Crohn’s disease or diverticulitis can damage parts of
the small intestine. Complications may include narrowing
of the bowel (strictures) or abnormal tunnel-like openings
(fistulas).
• Malignant (cancerous) tumors: Cancer accounts for a
small percentage of all small bowel obstructions.
SMALL BOWEL ADHESIONS
CAUSES OF INTESTINAL OBSTRUCTION
CLINICAL PRESENTATION

• The classical presentation is cramping

abdominal pain and abdominal distension with
nausea and vomiting.
• Severe constipation: In cases of complete
obstruction, a person will not be able to pass
stool (feces) or gas.
IMAGING :

• The initial radiological investigation for suspected

small bowel obstruction is supine and erect plain
abdominal films.
Radiological findings of small bowel obstruction
• Multiple dilated loops of the small bowel, usually
centrally placed in the abdomen.
• Multiple air-fluid levels.
• Absence of gas in the colon.
• Valvulae conniventes or small bowel folds (the
mucosal folds of the small intestine) are visible
 FRONTAL ABDOMINAL
X-RAY
DILATATION OF SMALL BOWEL LOOPS- 1
MORE THAN 5 CM
-2
AIR-FLUIDAIR FLUID
LEVEL
-3
ABSENCE OF GAS IN
THE COLON
-4
VALVULAE CONNIVENTES ARE VISIBLE

NORMAL SKELETAL/NO MASS/NO FREE

GAS(NO PERFORATION)
 CT SCAN
• CT is more sensitive than Plain Films of the Abdomen
and will demonstrate the cause in ~80% of cases
LARGE BOWEL OBSTRUCTION

• Large bowel obstruction (LBO) is often

impressive on imaging, on account of the
ability of the large bowel to massively distend.
• Large bowel obstructions are far less common
than small bowel obstructions, accounting for
only 20% of all bowel obstructions.
CLINICAL PRESENTATION

• The classic presentation is with

abdominal pain, distension, and
failure of passage of flatus and stool.
• As dilatation of the colon increases,
the risk of perforation also increases.
 Ist :- Colon CA
zed ! -
Acule diverticalitie
volvcl
zed : -Sigmoid

& MOST COMMON CAUSES OF LBO ARE:

• The most common cause is Colonic

Cancer (50-60%), typically in the sigmoid .
=
• The second most common cause in
adults is acute diverticulitis (involving the
sigmoid colon).
• Sigmoid volvulus (3-8%)
-
IMAGING :
Large bowel obstructions are characterized by colonic
distension proximal to the obstruction, with collapse
distally.
Plain Abdominal Films.
The plain abdominal film is useful for the diagnosis of
large bowel obstruction.
• Colonic distension.
• Collapsed distal colon.
• Small bowel dilatation.
• Rectum has little or no air.
DISTINCTION BETWEEN SMALL AND LARGE BOWEL
DILATATION

Small bowel Large bowel

Distribution of loops Central Peripheral
Number of loops Many Few
Diameter 2.5-3 cm 6 cm
Haustra Absent Present
Valvulae conniventes Present in jejunum Absent
Solid feces Absent Present
 /
dilatation of
Lecur
Massive

sigmoid
swing
CT SCAN best
>
-
Modat

• CT is currently the most widely used modality

for assessment of large bowel obstructions and
is not only able to confirm the diagnosis and
localize the location of obstruction but in most
cases also is able to identify the cause.
• The large bowel will be distended with a
thinned stretched wall but should enhance
(unless ischemic).
SIGMOID VOLVULUS

• Sigmoid volvulus is a cause of large bowel

obstruction and occurs when the sigmoid
colon twists on its mesentery, the sigmoid
mesocolon .
• The sigmoid mesocolon is a fold of peritoneum
that attaches the sigmoid colon to the pelvic
wall.
• It is more common in the elderly
CLINICAL PRESENTATION
• Symptoms are that of large bowel obstruction:
constipation, abdominal bloating, nausea and/or
vomiting. Onset may be acute or chronic.
• Etiology
• There is a wide range of causes; some are
geographically specific :
• Chronic constipation and/or laxative abuse
• Fiber-rich diet (especially in Africa)
PLAIN ABDOMINAL FILMS

• Dilated loop of the colon that almost fills the entire

abdomen, often with a few gas-fluid levels.
• Double- loop obstruction (50% of patients).
Coffee bean sign or Omega sign: inverted U shaped
appearance of distended sigmoid loop (the bowel
loop points to right upper quadrant).
• Loss of haustra.
 sigmoid volves
D
Bean
coffe
PNEUMOPERITONEUM

• is pneumatosis (abnormal presence of air or

other gas) in the peritoneal cavity, a potential
space within the abdominal cavity.
• The peritoneum is a large complex serous
membrane that forms a closed sac, the
peritoneal cavity, within the abdominal
cavity.
 THE PERITONEAL CAVITY
• is a potential space between the parietal
peritoneum and the visceral peritoneum

❖ The parietal peritoneum lines the walls of

the abdominal and pelvic cavities
❖ The visceral peritoneum covers the
organs.
CAUSES OF PNEUMOPERITONEUM
• Perforated hollow viscus
Are
They causes

• peptic ulcer disease

• ischemic bowel
• Postoperative free
• bowel obstruction SBO/LBO
intraperitoneal gas.
• necrotizing enterocolitis
• appendicitis
• diverticulitis • Peritoneal dialysis.
• malignancy
• inflammatory bowel disease
• mechanical perforation • Pneumomediastinum.
• trauma
• colonoscopy
• Pneumothorax .
• foreign bodies
• iatrogenic
RADIOLOGICAL SIGNS
CRESCENT SIGN

• This image shows a

very large volume
of gas under the
diaphragm due to
bowel perforation
RIGLER SIGN (DOUBLE WALL SIGN): &

• If there is free intra-

abdominal gas
adjacent to a gas-
filled loop of bowel
then both sides of
the bowel wall are
well-defined. This is
known as 'Rigler’s
sign'.
• The multiple loops of
dilated gas-filled
bowel indicate small
bowel obstruction.
• Rigler's sign is visible,
and so obstruction
has been
complicated by
perforation.
• When gas surrounds
multiple loops of
bowel there may be
formation of sharp
points or triangles
(arrowheads)
FALCIFORM SIGN
OR (SILVER SIGN)

• Linear density of
falciform ligament
outlined by air in
the upper right infant
quadrant
↳
A
head
femurpost
>
-
 56&
air
supine

↑
⑳@
 CONTINUOUS DIAPHRAGM SIGN:
• Massive
pneumoperitoneum-
sufficient air
beneath the
diaphragm
• -right and left
hemidiaphragms
contrasted by free
gas (appear as
continuous structure)
 FOOTBALL SIGN

*
-

S
↑
,
↑
i
↑

i ↑

↑
- Double
I
wall
sign

:
-

W
-
&
 FEW SPECIAL POINTS

DUODENAL ULCER TOXIC MEGA-COLON NECROTISING

PERFORATION ENTERO-COLITIS

Its the most Its a complication of Most common

common cause , inflammatory bowel cause in children
especially the diseases
anterior surface of mainly ulcerative
the Duodenum colitis
 GALLSTONES
What Are Gallstones?
• Gallstones are pieces of solid material that form in
your gallbladder .

• The gallbladder is a small pouch that sits just

under the liver. The gallbladder stores bile produced
by the liver. After meals, the gallbladder is empty and
flat, like a deflated balloon. Before a meal, the
gallbladder may be full of bile and about the size of a
small pear.
• Stones in the gallbladder are relatively common and
occur in approximately 10% of population.
 GALLSTONE TYPES

The two main kinds of gallstones are:

• Cholesterol and mixed stones. These are
usually yellow-green. They're the most common,
making up 80% of gallstones.
• Pigment stones. These are smaller and darker.
They're made of bilirubin .
RISK FACTORS

• female sex (F: M = 2:1).

• middle age
• obesity
• positive family history

E
• recent rapid weight loss
we
check
duck
bile
common
US
by
WHAT IS THE MAIN CAUSE OF GALLSTONES?

• As much as 75% of the gallstones healthcare

providers discover are made up of excess
cholesterol. So, we could say that having
excess cholesterol in your blood is the leading
cause of gallstones.
• You might have extra cholesterol for a variety
of reasons. Some of the most common reasons
include metabolic disorders, such as obesity
and diabetes.
IMAGING :

Ultrasound
• Ultrasound is considered the gold standard for
detecting gallstones .
• A gallstone on ultrasound is echogenic, it
appears as a white structure that casts a dark
shadow behind it.
PLAIN ABDOMINAL FILMS

• Some radiopaque gallstones may be seen on

plain film:
• gallstones are radiopaque only in 15-20% of
cases
• may show a Mercedes-Benz sign .
 ACUTE CHOLECYSTITIS
• Acute cholecystitis refers to the acute
inflammation of the gallbladder.
• It is the primary complication of
Gallstones and the most common cause
of acute pain in the right upper quadrant
(RUQ).
• Acute cholecystitis is a common cause of
hospital admission and is responsible for
approximately 3-10% of all patients with
abdominal pain.
CLINICAL PRESENTATION

• Constant right upper quadrant pain that can

radiate to the right shoulder.
• Pain typically persists for more than six hours .
• Nausea, vomiting, and fever are also often
reported.
PATHOLOGY
90-95% of cases are due to gallstones (i.e. acute calculous
cholecystitis) with the remainder being acute acalculous
cholecystitis .
The development of acute calculous cholecystitis follows a
sequence of events:
• gallstone obstruction of the gallbladder neck or cystic duct.
• inflammation from chemical injury of the mucosa by bile salts.
• reactive production of mucus, leading to increased intraluminal
pressure and distention
• increased luminal distention restricting blood flow to the gallbladder
wall (gallbladder hydrops or mucocele).
• increasing wall thickness from edema and inflammatory changes.
• secondary bacterial infection in ~66% of patients.
 ULTRASOUND
Ultrasound (US) is the initial modality in the investigation
of gallstones and the diagnosis of acute cholecystitis .

The most sensitive US finding in acute cholecystitis is the

presence of gallstone in combination with the
& sonographic Murphy sign.

gallbladder wall thickening (>3 mm) and pericholecystic

fluid .

Other findings include gallbladder distension and sludge.

 A cule cholesali

showe
>
-
pericholecystic
-echogenic Edema

I wall
Thicking