Gastrointestinal

Imaging
DR. VINI NILASARI, SPRAD
Anatomy
 The salivary glands are exocrine glands,
glands with ducts, that produce saliva
and pour their secretion in the oral
cavity
 Major (paired)
 Parotid
 Submandibular
 Sublingual

 Minor
 Those in the tongue, palatine tonsil, palate, lips,
and cheeks

SALIVARY GLAND
 From : sup. oesophageal sphincter (inferior border of
cricoid cartilage → 6th cervical spine
 To: inf. oesophageal sphincter → 11th thoracic spine
 Length: 25 cm
 Diameter : 2 cm
 Wall (from outside to inside)
 Fibrous
 Muscular
 Submucosa
 Mucosa (squamous changing to columnar in
oesophagogastric junction → Z line)

Oesophagus
Oesophagus
 Normal physiological stenoses
 Pharyngoesophageal junction
 Aortic arch
 Left main bronchi
 Oesophageal hiatus

Oesophagus
 Wall (from outside  4 part
to inside)  Cardia
 Serosa  Fundus
 Muscularis  Corpus
 Submucosa  Pylorus
 Mucosa

Stomach
Stomach
Stomach
Stomach
 Normal : 2-5 simultaneous peristaltic wave
 High activity in the distal part
 Barium clearance : max in 1-2 hour
3 hour → no remnant
 Barium retention > 6 hours → pathologic
 Children retention > 8 hours → pathologic

Stomach
 Stomach
 Patient position will affect the
appearance of the barium in the
stomach
Small Intestine

 From pylorus to ileocaecal valve

 Length: 5.5 – 6 m
 Consist of
 Duodenum
 Jejunum
 Ileum
Small Intestine
Duodenum

 Duodenum → 1st part of small intestine

 Length : 20-24 cm
 The shortest, the widest and the most fixated
among the small intestine
 C-loop → surround pancreatic head
Duodenum
Jejunum

 Length : ± 2m
 From : duodenojejunal flexura (lig. Treitz)
 Left upper quadrant
 Diameter :
 Proximal : 3 – 4 cm (>4.5cm → pathologic)
 Distal : 2.5 – 3.5 cm (>4 cm → pathologic)
 Mucosal fold thickness : 1.7 – 2 mm (>2.5 mm →
pathologic)
 4 -7 mucosal fold / 2.5 cm
Ileum

 Length : ± 3m
 To: ileocaecal valve (valvula Bauhini)
 Right lower quadrant
 Diameter : 2 – 2.8 cm (>3cm → pathologic)
 Mucosal fold thickness : 1.4 – 1.7 mm (>2 mm →
pathologic)
 2 - 4 mucosal fold / 2.5 cm
Rule of 3

 Mucosal fold thickness < 3 mm

 Bowel wall thickness < 3 mm
 Diameter of the small intestine< 3 cm
 Air fluid level / loop < 3
 Diameter of the large intestine< 6 cm
 Diameter of the caecum < 9 cm
Transit Time
 Barium transit time to ileocaecal valve
→ 2 – 3 hour
 Vary between 3 – 11 hour
 Depend on the dietary type
Large Intestine

 Large intestine consists of caecum, colon, rectum,

and anal canal.
 Colon consists of :
 Ascending colon
 Hepatic flexure
 Transverse colon
 Splenic flexure
 Descending colon
 Sigmoid colon
Large Intestine
Large Intestine

 The length of large intestine ± 1.5 m.

 Wall
 Mucosa
 Submucosa
 Muscularis propia
 Circular
 Longitudinal → 3 taenia coli / plica semicircularis

 Taenia is shorter than other part

→ sacs or haustra
 Serosa
Large Intestine

 Function :
 Water reabsorption
 Elimination of waste products
 Caecum
 Between the ileum and colon
 Length 6 cm
 The largest
 Diameter : 7.5 cm (Max: 9cm)
Large Intestine

 Appendix
 Posteromedial side of caecum
 Length 2-20cm
 Ileocaecal valve
 Just below the border between the caecum and
ascending colon
 To prevent reflux from the large intestine to the
ileum (do not always function properly)
Caecum, Terminal
Ileum, and Appendix
Caecum, Terminal
Ileum, and Appendix
Large Intestine

 Transit time : 20-

71 hour
 Depend on
dietary type
Large
Intestine
 Variation in length
(redundant)
Large
Intestine
 Physiological
constriction
 Not persistent
Rectum

 Start at the level of third segment of sacrum

 Length : 12-15cm
 About 2.5-4 cm distal part will constrict → anal
canal
 Ampulla recti → dilated and proximal part of
rectum
Rectum
Intraperitoneal Retroperitoneal Infraperitoneal/Pelvic
 Liver • Kidneys • Lower rectum
 Gallbladder • Ureters • Urinary bladder
 Spleen • Adrenal glands • Reproductive organs
 Stomach • Pancreas • Male-closed sac
 Jejunum • Duodenum(2nd&3rd • Female-open sac
part)
 Ileum
• Ascending colon
 Cecum
• Descending Colon
 Transverse
• Upper rectum
colon
• Major abdominal
 Sigmoid colon
blood vessels (aort
and inferior vena
cava)

Intra and
Retroperitoneal Organ
LIVER
SPLEEN
Radiology Examination and
Procedure
 Plain abdominal radiograph / KUB / BNO
 Three-way series / BNO 3 posisi
 Esophagography
 Esophagomaagduodenography / OMD
 Barium Follow Through (BFT)
 Colon In Loop
 Enterostomy / Lopography
 Barium Enema Modification
 T-Tube Cholangiography
 Sialography

Radiology Examination
and Procedure
Plain Abdominal
Radiograph
 BNO (Buik, Nier, Overzicht : Abdomen,
Kidney, Overview)
 KUB (Kidney, Ureter, Bladder)
 Indication
1. Abdominal, flank, or pelvic pain. 12. Obstructive voiding symptoms.
2. Vomiting. 13. Evaluation for and follow-up of
urinary tract calculi.
3. Abdominal distention, bloating,
or increased girth. 14. Blunt or penetrating abdominal
trauma.
4. Evaluation for and follow-up of
bowel obstruction or 15. Search for foreign bodies.
nonobstructive ileus. 16. Assessment of residual contrast
5. Constipation. in the gastrointestinal tract that
might interfere with a planned
6. Diarrhea.
imaging examination.
7. Evaluation for necrotizing
17. Evaluation of suspected
enterocolitis in the premature
calcifications found on other
newborn.
imaging studies.
8. Palpable abdominal mass or
organomegaly. 18. Evaluation of the position of
medical devices.
9. Evaluation of congenital
19. Evaluation for
 Right Upper Quadrant
 Left Upper Quadrant
 Right Lower Quadrant
 Left Lower Quadrant

Plain Abdominal
Radiograph
 Right hypochondriac
 Epigastric
 Left hypochondriac
 Right lateral (lumbar)
 Umbilical
 Left lateral (lumbar)
 Right inguinal (iliac)
 Pubic (hypogastric)
 Left inguinal (iliac)

Plain Abdominal
Radiograph
What aspect that we need to assess:
 Preperitoneal Fat (Abdominal wall)
 Psoas line
 Size, position and contour of the kidney (organ)
 Air distribution in the small bowel
 Air distribution in the large bowel
 Pathologic lucency
 Opaque shadow/calcifications
 Soft tissue and skeletal

Plain Abdominal
Radiograph
Preperitoneal Fat
 Syn: flank stripe or paracolic gutter
 Can be displaced by organs or fluid
 May be blurred by inflammation or fluid
 Preperitoneal fat is lost in 18% of normal individual
 Exposure and quality of the film should be also be
considered

Plain Abdominal
Radiograph
Plain Abdominal
Radiograph
Abdominal Wall
 A. Parietal peritoneum
 B. Preperitoneal Fat
 C. Transverse abdominis
Muscle
 D. Internal Oblique Muscle
 E. External Oblique Muscle
Widening of preperitoneal fat in ascites
Psoas line
 Can be displaced by organs or fluid (psoas abscess,
neoplasm)
 May be blurred by inflammation or fluid
 In 19% of normal people the right psoas outline is blurred
 In 52% of children the psoas outlines are lost.
 Exposure and quality of the film should be also be
considered

Plain Abdominal
Radiograph
Psoas line
Psoas line
Psoas line
 Blurring of the right psoas line
 Appendicitis (unreliable)
 Blurring of the left psoas line
 Pancreatitis
 Blurring of both psoas lines
 Peritonitis
 Ascites
 Ruptur of aneurysm

Plain Abdominal
Radiograph
Blurring of both Psoas Line
in Ruptur of Aneurysm
Plain Abdominal
Radiograph
Organomegaly
 Conventional radiograph → limited
 Two ways
 Direct visualization of the edges → fat or free air
 Indirect → displacement of air-filled loops of bowel
Normal Liver
Hepatomegaly
Size, Position and Contour of the Spleen
 Length : 12cm
 Doesn’t project below the 12th posterior rib
 As large as the left kidney
 Enlarged
 Projects below the 12th posterior rib
 Displace the stomach bubble across the midline

Plain Abdominal
Radiograph
Normal Spleen
Splenomegaly
 Plain Abdominal
Radiograph
Normal Gas Pattern
 Virtually all gas in the bowel comes from swallowed air
 Only a fraction comes from bacterial fermentation
 Stomach
 Almost always air in the stomach
 Unless : recently vomited or NGT with suction
Stomach
 Air in the LUQ
 Lower part cross the midline
 Plain Abdominal
Radiograph
Normal Gas Pattern
 Small Bowel
 Small amount of air in about 2-3 loops of nondistended small bowel
 Normal diameter < 2.5-3cm
 Distended→ within normal size → normal
 Dilatation → beyond normal size → abnormal
 Plain Abdominal
Radiograph
Normal Gas Pattern
 Large Bowel
 Almost always air in the rectum or sigmoid
 Varying amount of gas in the remainder of the colon
 Diameter < 6cm (caecum <9cm)
 Stool / fecal material → multiple small bubbles of gas within a
semisolid-appearing mass → sign of large bowel
Aerophagia
/ Meteorism
 Plain Abdominal
Radiograph
Differentiating Large from Small Bowel
 Small bowel
 Centrally placed
 Valvulae markings extend across the lumen
 Valvulae are spaced much closer together
 Diameter <3cm (even if there is dilatation, the max. Diameter <5cm)
 No fecal material.
 Air fluid level and air in 2-3 loops
 Plain Abdominal
Radiograph
Differentiating Large from Small Bowel
 Large bowel
 Peripherally placed (picture frame), mostly not overlapping except
in redundancy
 Valvulae markings do not extend completely across the lumen
(depend on the view)
 Valvulae are more widely apart
 Diameter are larger than small bowel (3-6cm)
 With fecal material.
 Air fluid level are minimal.
 More air distribution than the small bowel
Plain Abdominal Radiograph
Plain Abdominal
Radiograph
Small bowel
Valvulae in Small Bowel
Large bowel
 1. Caecum
 2. Colon ascending
 3. Colon transverse
 4. Colon descendng
 5. Colon sigmoid
Valvulae in Large Bowel
 Plain Abdominal
Radiograph
Pathogenic lucency
 Pneumatosis intestinalis
 Free air intraperitoneal
 Air fluid level (intra an extraluminal)
 Portal venous gas
 Plain Abdominal
Radiograph
Pneumatosis intestinalis
 Plain Abdominal
Radiograph
Free air intraperitoneal
 Plain Abdominal
Radiograph
Pneumatosis intestinalis
 Plain Abdominal
Radiograph
Pneumatosis intestinalis
 Plain Abdominal
Radiograph
Portal Venous Gas
 Plain Abdominal
Radiograph
Opaque shadow/calcifications
 Calcification implies a process that is subacute/chronic
 Nature of most calcifications can be determined
 Pattern of calcification
 Anatomic location
 Pattern of calcification
 Rimlike
 Linear or track-like
 Lamellar (or laminar)
 Cloudlike, amorphous, or popcorn
 Plain Abdominal
Radiograph
Rimlike Calcification

Renal cyst Gallbladder wall

Rimlike Calcification
Porcelain Gallbladder

Plain Abdominal
Radiograph
 Plain Abdominal
Radiograph
Lamellar or Laminar Calcification
Plain Abdominal
Radiograph
Appendicolith
Plain Abdominal
Radiograph
Phlebolith
Nephrocalcinosis Myomatous Uterus
 Plain Abdominal
Radiograph
Soft tissue and Skeletal
 Ribs
 Lumbar spine
 Sacrum
 Skeletal also function as landmarks
 The transverse processes → ureter
 Ischial spine → vesicoureteric junction
Three-way Series
 Consist of
 Supine abdominal x ray
 Erect abdominal x ray
 Left lateral decubitus
 PA erect chest x ray
 Indicated to be part of a three-way acute
abdomen
 Modification
 Supine abdominal x ray
 Erect abdominal x ray
 PA erect chest x ray
PEMERIKSAAN PROSEDUR
DENGAN
KONTRAS
Esophagography

Normal
esophagus
Barium Meal/
Barium Swallow/
Maag
Duodenography
 Patient position will affect the
appearance of the barium in the
stomach
Gastric
ulcer
Duodenal
ulcer
Barium Follow Trough
Colon in
Loop
Ulcerative Colitis
APPENDICOGRAM
Thank you for your
attention