Guide for imaging for undergraduates

1. University of
Alexandria
Imaging
GI Surgery Unit
Faculty of Medicine
University of Alexandria
By: Mohamed Mourad
Assistant lecturer of general surgery

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Alexandria
Different imaging modalities

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Plain chest x-ray

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Alexandria
Plain X-ray Chest postero-anterior
view

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Alexandria
Ideal chest x-ray PA view
 Trachea mid way between the 2 clavicles
 1/3 of the heart lies in the Rt side of the
midline
 Visible upper diaphragmatic surface from one
costophrenic angle to the other

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Alexandria
Normal plain chest x-ray PA veiw

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Alexandria
Plain chest x-ray PA veiw

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Alexandria
Plain standing x ray PA view showing
Free air under diaphragm

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Alexandria
Plain standing x ray PA view showing
Free air under diaphragm

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Alexandria
Air under diaphragm

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Alexandria
Plain x ray PA & lateral view showing
Foreign body in thoracic esophagus

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Alexandria
Congenital diaphragmatic hernia

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Plain abdomen x-ray

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Alexandria
Plain X-ray abdomen supine

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Alexandria
Plain X-ray abdomen standing

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Alexandria
Plain X-ray abdomen

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Alexandria
Plain x ray abdomen and pelvis PA
view showing Radio-opaque shadow

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Alexandria
DD radio-opaque shadow of
Rt. hypochondrium
 Gall bladder stones
 Renal stones (Dx Lat X-ray &
US)
 Porcelain gall bladder
 Calcified LN
 Fracture tr. Process of
vertebra
 FB
 Fecolith
 Calcified hydatid cyst

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Alexandria
DD: renal & gall bladder stones

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Alexandria
Radio-opaque shadow of the
abdomen x ray

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Alexandria
Chronic panreatitis

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Alexandria
Erect Plain x-ray abdomen &pelvis
PA view showing Distended bowel
loops and Multiple air fluid levels
 Distended
Jejunal loops
– Central
– Valvae
conniventes

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Alexandria
Plain x-ray abdomen &pelvis PA view
showing Distended bowel loops
 Distended Ileal
loops
– Central
– featureless

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Alexandria
Plain x-ray abdomen &pelvis PA view
showing Distended bowel loops
 Distended
Colon
– peripheral
– Colonic
hausteration

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Alexandria
Plain x-ray abdomen & pelvis
showing distended colonic loops

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Alexandria
Ileo-ceacal valve

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Alexandria
Post operative adynamic ileus
•SupineSupine •ErectErect

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Alexandria
Sigmoid Volvulus

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Alexandria
Plain x-ray abdomen and pelvis
showing pneumatic tyre appearance

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Alexandria
Plain x-ray abdomen and pelvis
showing pneumatic tyre appearance

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Alexandria
Plain x-ray abdomen and pelvis
showing coffee bean appearance
 Sigmoid volvulus--
bowel loop points
to RUQ
 Caecal volvulus--
bowel loop points
to LUQ

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Alexandria
Caecal volvulus

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Alexandria
Plain x ray abdomen & pelvis
showing double bubble sign

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Alexandria
Plain x-ray abdomen and pelvis
Foreign body

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Alexandria
Plain x ray abdomen showing
aeroblia

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Alexandria
Invertogram

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Barium swallow

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Alexandria
Barium swallow
 Technique
 Normal indentation
– Aortic arch
– Lt main bronchus

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Alexandria
Pathologies by barium swallow

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Alexandria
Achalasia of the cardia

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Alexandria
Barium swallow showing smooth
narrowing of distal end of the
oesophagus with proximal dilatation

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Alexandria
Barium swallow showing smooth
long narrowing of middle 1/3
oesophagus
 Corrosive stricture
– Single or multiple
– Long segment
– Smooth tapering
– Usually in children
– Starts at aortic arch
level

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Alexandria
Corrosive stricture

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Alexandria
Barium swallow showing Corkscrow
oesophagus

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Alexandria
Irregular filling defect mostly Cancer
oesophagus

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Alexandria
Oesophageal malignancy

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Alexandria
Oesophageal malignancy

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Alexandria
DD between achalasia and
malignancy
•The cardia is normally
below the diaphragm
•In X-ray 11, the
oesophagus is
interrupted above
the diaphragm
•In X-ray 22, the
cardia below the
diaphragm is
closed with “bird
beak-like” shape

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Alexandria
serpiginous filling defects in the
oesophagus Oesophageal
varices

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Alexandria
Barium swallow with outpouch of the
barium--Oesophageal diverticula

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Alexandria
Epiphrenic and Zenker’s diverticulum

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Alexandria
Oesophageal web

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Barium meal

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Alexandria
Barium meal

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Alexandria
Barium meal
 Large volume low
density
 Distension of
stomach by
volume
 Small volume high
density+ effervescent
 Distension of stomach
by buscopan

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Alexandria
Barium meal (Single & Double)

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Alexandria
Barium meal
 1, Gastric antrum
 2, pyloric canal
 3, duodenal cap
 4, duodenal loop

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Alexandria
Pathological findings in barium meal

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Alexandria
Hiatal hernia

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Alexandria
Barium meal in trendlenberg position
showing Sliding hiatal hernia

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Alexandria
Barium meal in trendlenberg position
showing Sliding hiatal hernia

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Alexandria
Barium meal in trendlenberg position
showing Sliding hiatal hernia

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Alexandria
Barium meal in trendlenberg position
showing paraoesophageal hiatal hernia

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Alexandria
Barium meal in trendlenberg position
showing paraoesophageal hiatal hernia

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Alexandria
Barium meal showing
paraoesophageal hiatal hernia

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Alexandria
Barrett’s oesophagus

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Alexandria
Benign gastric ulcer

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Alexandria
Benign gastric ulcer
 On lesser curvature
 Convergence of
mucosal folds
 Out pouch

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Alexandria
Barium meal showing ulcer nich at the middle of
lesser curvature with mucosal convergence
Benign gastric ulcer

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Alexandria
Hour glass deformity

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Alexandria
Normal duodenal cap and DU

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Alexandria
2 kissing duodenal ulcers

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Alexandria
Trifoliate deformity of DU

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Alexandria
Gastric tumors

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Alexandria
Malignant gastric ulcer

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Alexandria
Malignant gastric ulcer
 Any site of stomach mainly antrum and
greater curvature
 Ulcer dose not protrude to the outside
 Mucosal folds obliterate before the edges of
the ulcer

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Alexandria
Lintis plastica

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Alexandria
Pyloric filling defect of malignant
origin

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Alexandria
Pre-pyloric tumor

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Alexandria
Duodenal diverticulum

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Alexandria
Barium meal showing dilated stomach reaching
pelvis with mottled dye without passage of dye
to dudenum (Gastric outlet obstruction)

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Alexandria
Barium meal showing Soap dish
appearance

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Alexandria
Congenital hypertrophic pyloric
stenosis

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Alexandria
GOO by compression from outside

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Alexandria
GOO by pseudopancreatic cyst

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Alexandria
Volvulus of the stomach
•Organoaxial volvulusOrganoaxial volvulus •Mesenteroaxial volvulus

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Alexandria
Organo-axial volvulus

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Alexandria
Duodenal atresia

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Barium follow through

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Alexandria
Barium follow through

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Alexandria
Stricture of small intestine
•Chron’s
•Lymphoma
•TB
•Radiation

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Alexandria
Chron’s stricture
 Commonly at terminal
ileum
 Multiple, rigid, irregular
stricture (string sign of
Kantor)
 Skip lesions
 Cobble stones
 Polyps
 Fistula

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Barium enema

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Alexandria
Barium enema

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Alexandria
Normal barium enema filling phase

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Alexandria
Pathological findings in barium enema

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Alexandria
Transverse colon filling defect

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Alexandria
Transverse colon filling defect
(colonic malignancy)

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Alexandria
Cancer ascending colon

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Alexandria
Barium enema showing arrest of the
dye at the level of rectosegmoid
junction due obstruction of the lumen

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Alexandria
Diverticulosis

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Alexandria
Chron’s disease
 Commonly at terminal ileum
 Multiple, rigid, irregular
 Skip lesions
 Cobble stones
 Polyps
 Fistula
 Loss of hausterations

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Alexandria
Ulcerative colitis
 Rectosegmoid
 Loss of hausteration
 Polyps
 No skip lesion
 Narrow colon (lead pipe)

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Alexandria
Ischemic colitis
 segmental narrowing
of the entire
transverse colon.
 Within the narrowed
segment, there are
multiple nodular
indentations, many of
which have the
appearance of
thumbprinting

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Alexandria
DD of colonic stricture
 Chron’s caecum
 TB iliocecal
 Cancer segmoid
 Diverticulitis segmoid
 Ischemic colitis splenic flexure

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Alexandria
Hirschsprung disease
 Stenotic segment
 Dilated rectum
 Transitional zone
(funnel)
 Delayed
evacuation

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Alexandria
Rounded filling defect (polyps)

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Alexandria
Rectosegmoid polyps

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Alexandria
Barium enema showing hundreds of
filling defects of the entire colon (FAP)

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Alexandria
Intussusception

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Alexandria
Intussusception

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Alexandria
Barium reduction of intussusception
•Head of intussusception
is at hepatic flexure
•Free flow of contrast into
distal small bowel indicates
complete reduction
•Partial reduction

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Biliary imaging

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Alexandria
Types

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Oral Cholecystography (OCG)Oral Cholecystography (OCG)

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Alexandria
Steps of oral cholecystographySteps of oral cholecystography
(OCG)(OCG)
 Control X-ray
 Ingestion of telepaque
 Another X-ray 12hrs latter
 Intake of fatty meal
 Another X-ray 2hrs latter
Remember that 85% of gallstones are
radiolucent
Remember that 85% of gallstones are
radiolucent

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Alexandria
Oral cholecystography (OCG)Oral cholecystography (OCG)

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Alexandria
Oral cholecystography (OCG)Oral cholecystography (OCG)
 Site--- (bt. 12th
rib & LV1)
 Size--- (Contraction with fatty meal)
 Shape
 Filling defect
 Function (concentration & contarction)

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Alexandria
Gall stones in OCGGall stones in OCG

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Alexandria
Non visualized gall bladder in OCG
 Absent gall bladder
 Stone in cystic duct
 Non functioning gall
bladder

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Cholangiogram

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PTC

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Alexandria
Normal PTCNormal PTC

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Alexandria
CBD stone-PTCCBD stone-PTC

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Alexandria
CBD stone-PTCCBD stone-PTC
 One or more intraluminal
defects (round, faceted or
lobulated) which produce
varying degrees of biliary
obstruction are seen.
 Occasionally stones are
noted as small multiple
free-floating defects in a
non-dilated duct.

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Alexandria
CBD stricture PTC
Transhepatic
cholangiogram showing a
stricture of the common
hepatic duct

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Alexandria
PTC with iatrogenic injury of CHD
with biloma

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ERCP

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Alexandria
Normal ERCPNormal ERCP
•Common bileCommon bile
ductduct
•Gall bladder
•Common hepaticCommon hepatic
ductduct
•Rt. & Lt. hepaticRt. & Lt. hepatic
ductsducts

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Alexandria
CBD stone-ERCP

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Alexandria
CBD stone-ERCP

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Alexandria
CBD stone-ERCP

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Alexandria
CBD stone-ERCP

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Alexandria
Multiple intrahepatic & extrahepatic
stones

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Alexandria
Bile duct carcinoma-ERCPBile duct carcinoma-ERCP
 A short segment
constricting lesion
with irregular
margins was noted
at the bifurcation of
the common hepatic
duct (Klatskin
tumour)

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Alexandria
Stents insertion-ERCP

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T-tube cholangiogram

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Alexandria
Normal T-tube cholangiogram

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Alexandria
Normal T-tube cholangiogram

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Alexandria
CBD stone, T-Tube

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Alexandria
T-tube cholangiogram with CBD
stone

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Alexandria
CBD stone, T-Tube

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Alexandria
Transcystic IO cholangiogram

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Alexandria
Transcystic IO cholangiogram

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Alexandria
Radiological pattern reflecting the
cause of biliary obstruction
 CholedocholithiasisCholedocholithiasis
(biliary duct stones)
– One or more intraluminal
defects (round, faceted or lobulated)
– Occasionally stones are noted
as small multiple free-floating
defects in a non-dilated duct.
– Sometimes impacted with
crescent sign.

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Alexandria
Radiological pattern reflecting the
cause of biliary obstruction
 PancreaticPancreatic
carcinomacarcinoma
– Complete or almost
complete obstruction of
the mid or distal common
duct, usually over a long
segment (3-4 cm) of the
distal duct
(intrapancreatic portion)
is seen.
– A "rat-tail" configuration is
the typical appearance

147. University of
Alexandria
Radiological pattern reflecting the
cause of biliary obstruction
 CholangiocarcinomCholangiocarcinom
aa
– The narrowing may
occur at any level and
typically presents as a
segmental stenosis.
– When the lesion is
located at the
bifurcation, it is referred
to as a Klatskin tumor

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Alexandria
Radiological pattern reflecting the
cause of biliary obstruction
 Benign strictureBenign stricture
– There is a short segmental
circumferential stricture in
the mid-common duct in a
patient with a previous
cholecystectomy.
– Most benign strictures are
secondary to ductal injury
during cholecystectomy.
(iatrogenic)

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Alexandria
Radiological pattern reflecting the
cause of biliary obstruction
 AmpullaryAmpullary
carcinomacarcinoma
– Focal obstruction of very
distal CBD is noted.
– A smooth constriction or
an irregular polypoid mass
growing into distal CBD
may be seen.

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Alexandria
Radiological pattern reflecting the
cause of biliary obstruction
 Ascariasis
– Worms are seen
extending through the
common bile duct and
major hepatic ducts

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MRCP

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Alexandria
Normal MRCP

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Alexandria
CBD stones-MRCP

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Alexandria
Klatskin tumor-MRCP

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Alexandria
Biliary injury-MRCP

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Liver imaging

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Alexandria
Hydatid liver cyst
 Fluid attenuation
 No peripheral
enhancement
 Daughter cysts
 Well defined
 Rounded or oval

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Alexandria
Hydatid cyst

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Imaging
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