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

2. Different imaging modalities
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Alexandria

3. Plain chest x-ray
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4. Plain X-ray Chest postero-anterior
view
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Alexandria

5. 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

6. Normal plain chest x-ray PA veiw
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Alexandria

7. Plain chest x-ray PA veiw
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Alexandria

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

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

10. Air under diaphragm
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Alexandria

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

12. Congenital diaphragmatic hernia
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Alexandria

13. Plain abdomen x-ray
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14. Plain X-ray abdomen supine
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Alexandria

15. Plain X-ray abdomen standing
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Alexandria

16. Plain X-ray abdomen
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Alexandria

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

18. 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

19. DD: renal & gall bladder stones
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Alexandria

20. Radio-opaque shadow of the
abdomen x ray
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Alexandria

21. Chronic panreatitis
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Alexandria

22. Erect Plain x-ray abdomen &pelvis
PA view showing Distended bowel
loops
 Distended
Jejunal loops
–
–
Central
Valvae
conniventes
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Alexandria

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

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

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

26. Post operative adynamic ileus
•Supine
•Erect
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Alexandria

27. Plain x-ray abdomen and pelvis
showing pneumatic tire appearance
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Alexandria

28. Plain x-ray abdomen and pelvis
showing pneumatic tire appearance
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Alexandria

29. Plain x ray abdomen & pelvis
showing double bubble sign
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Alexandria

30. Plain x-ray abdomen and pelvis
Foreign body
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Alexandria

31. Plain x ray abdomen showing
aeroblia
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Alexandria

32. Invertogram
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Alexandria

33. Oral Cholecystography
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34. Steps of oral cholecystography
(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
Remember that 85% of gallstones are
radiolucent
radiolucent
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Alexandria

35. Oral cholecystography (OCG)
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Alexandria

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

37. Gall stones in OCG
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Alexandria

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

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

41. Pathologies by barium swallow
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Alexandria

42. Achalasia of the cardia
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Alexandria

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

44. 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

45. Corrosive stricture
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Alexandria

46. Barium swallow showing Corkscrow
oesophagus
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Alexandria

47. Irregular filling defect mostly Cancer
oesophagus
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Alexandria

48. Oesophageal malignancy
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Alexandria

49. Oesophageal malignancy
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Alexandria

50. DD between achalasia and
malignancy
•The cardia is normally
below the diaphragm
•In X-ray 1, the
oesophagus is
interrupted above
the diaphragm
•In X-ray 2, the
cardia below the
diaphragm is
closed with “bird
beak-like” shape
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Alexandria

51. serpiginous filling defects in the
oesophagus Oesophageal
varices
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Alexandria

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

53. Epiphrenic and Zenker’s diverticulum
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Alexandria

54. Oesophageal web
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Alexandria

55. Barium meal
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56. Barium meal
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Alexandria

57. 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

58. Barium meal (Single & Double)
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Alexandria

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

60. Pathological findings in barium meal
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Alexandria

61. Hiatal hernia
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Alexandria

62. Barium meal in trendlenberg position
showing Sliding hiatal hernia
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Alexandria

63. Barium meal in trendlenberg position
showing Sliding hiatal hernia
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Alexandria

64. Barium meal in trendlenberg position
showing Sliding hiatal hernia
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Alexandria

65. Barium meal in trendlenberg position
showing paraoesophageal hiatal hernia
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Alexandria

66. Barium meal showing
paraoesophageal hiatal hernia
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Alexandria

67. Barrett’s oesophagus
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Alexandria

68. Benign gastric ulcer
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Alexandria

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

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

71. Hour glass deformity
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Alexandria

72. Normal duodenal cap and DU
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Alexandria

73. 2 kissing duodenal ulcers
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Alexandria

74. Trifoliate deformity of DU
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Alexandria

75. Gastric tumors
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Alexandria

76. Malignant gastric ulcer
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Alexandria

77. 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

78. Lintis platica
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Alexandria

79. Lintis plastica
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Alexandria

80. Pyloric filling defect of malignant
origin
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Alexandria

81. Pre-pyloric tumor
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Alexandria

82. Duodenal diverticulum
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Alexandria

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

84. Barium meal showing Soap dish
appearance
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Alexandria

85. Congenital hypertrophic pyloric
stenosis
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Alexandria

86. GOO by compression from outside
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Alexandria

87. GOO by pseudopancreatic cyst
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Alexandria

88. Volvulus of the stomach
•Organoaxial volvulus
•Mesenteroaxial volvulus
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Alexandria

89. Organo-axial volvulus
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Alexandria

90. Duodenal atresia
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Alexandria

91. Barium follow through
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92. Barium follow through
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Alexandria

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

94. 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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Alexandria

95. Barium enema
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96. Barium enema
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Alexandria

97. Normal barium enema filling phase
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Alexandria

98. Pathological findings in barium enema
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Alexandria

99. Transverse colon filling defect
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Alexandria

100. Transverse colon filling defect
(colonic malignancy)
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Alexandria

101. Cancer ascending colon
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Alexandria

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

103. Diverticulosis
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Alexandria

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

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

106. 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

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

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

109. Rounded filling defect (polyps)
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Alexandria

110. Rectosegmoid polyps
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Alexandria

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

112. Intussusception
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Alexandria

113. Intussusception
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Alexandria

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

115. Biliary imaging
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116. Types
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Alexandria

117. PTC
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118. Normal PTC
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Alexandria

119. CBD stone-PTC
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Alexandria

120. CBD 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.
University of
Alexandria

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

122. ERCP
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123. Normal ERCP
•Common bile
duct
•Gall bladder
•Common hepatic
duct
•Rt. & Lt. hepatic
ducts
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Alexandria

124. CBD stone-ERCP
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Alexandria

125. CBD stone-ERCP
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Alexandria

126. CBD stone-ERCP
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Alexandria

127. Multiple intrahepatic & extrahepatic
stones
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Alexandria

128. Bile 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

129. Stents insertion-ERCP
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Alexandria

130. Cholangiogram
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131. Normal T-tube cholangiogram
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Alexandria

132. Normal T-tube cholangiogram
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Alexandria

133. CBD stone, T-Tube
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Alexandria

134. CBD stone, T-Tube
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Alexandria

135. Transcystic IO cholangiogram
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Alexandria

136. Transcystic IO cholangiogram
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Alexandria

137. Radiological pattern reflecting the
cause of biliary obstruction
 Choledocholithiasis
(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.
University of
Alexandria

138. Radiological pattern reflecting the
cause of biliary obstruction
 Pancreatic
carcinoma
–
–
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
University of
Alexandria

139. Radiological pattern reflecting the
cause of biliary obstruction
 Cholangiocarcinom
a
–
–
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
University of
Alexandria

140. Radiological pattern reflecting the
cause of biliary obstruction

Benign 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)
University of
Alexandria

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

142. 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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Alexandria

143. MRCP
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144. Normal MRCP
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Alexandria

145. CBD stones-MRCP
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Alexandria

146. Klatskin tumor-MRCP
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Alexandria

147. Biliary injury-MRCP
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Alexandria

148. Liver imaging
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149. Hydatid liver cyst
 Fluid
attenuation
 No
peripheral
enhancement
 Daughter
 Well
cysts
defined
 Rounded
or oval
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Alexandria

150. Imaging
Thank You
University of Alexandria