gastrointestinal tract radiology revison notes

Barium swallow Barium paste Esophagus
Barium meal 95 % BaSO4 Stomach & duodenum
Barium meal follow through 50 % BaSO4 Small intestine
Barium enema 25 % BaSO4 Large bowel
TONY SCARIA 2010 KMC

Barium meal follow through

Double contrast barium enema
Double contrast barium enema
Positive contrast Negative contrast
Barium enema CO2 or air (by using effervescent
tablet )
• Thick barium coats the lumen & effervescent tablet distend lumen with
air
• Better assessment of mucosal details
• Better distension & separation of bowel loops

esophagus

Motility disorders Carcinoma
Gold standard is manometry Barium enema

Diffuse esophageal spasm

Diffuse esophageal spasm
• Corck screw appearance
• Sacculations & pseudo divrticulae
• Below aortic arch
• Non propagated contractions

• Diffuse esophageal spasm is diagnosed by
• Manometry

DES vs nut cracker esophagus

Nut cracker esophagus
• peristaltic sequence is normal and
• peristaltic amplitude and duration is increased in distal esophageal
body
• Rx
• Treatment should be aimed at GERD as it is unclear that chest pain in
nutcracker eso is due to acid reflux or intraluminal hypertension

carcinoma esophagus
• Shouldering of esophagus
• Rat tail appearance

rat tail appearance
• Barium swallow in the image shows the
typical rat tail appearance which is seen in
carcinoma of esophagus. The malignancy has
an asymmetric contour with abrupt proximal
borders of narrowed distal segment giving rat
tail appearance.
• Chest radiographs may show adenopathy, a
widened mediastinum, pulmonary or bony
metastases, or signs of tracheo-esophageal
fistula such as pneumonia

Achalasia cardia  bird beak sign
• Mega esophagus
• Bird beak
• MANOMETRY is gold standard
• 2*achalasia
• Chagas disease
• ALLGROVE SYNDROME

Allgrove syndrome
• Alacrimia
• Achalasia
• Adrenal insufficiency

Achalasia cardia
• in achalasia myenteric plexus is deficient at LES  release of NO and
VIP is defective
• PRESSURE AT DISTAL END INCREASED WITH NO PERISTALSIS
• HYPERTENSIVE LES/ INCREASED LES RESTING TONE is primary pathology in
ACHALASIA . it is bcoz of dysfunction of inhibitory neurons releasing NO and
VIP so that acetylcholine releasing excitatory vagal fibres take upper hand

Manometry gold standard for achalasia cardia
• Rx
• Hellers myotomy

Bird beak appearance
in achalasia cardia

Pulmonary sling  produces anterior
impression on esophagus

Anomalous left pulmonary A produces
impression on anterior surface of esophagus

Aberrant Rt subclavian A (LUSORIAN ARTERY)
compresses posterior wall of esophagus

Can also be compressed by aberrant Lt
subclavian A from Rt sided aortic arch

CMV esophagitis

Esophageal carcinoma
• Irregular narrowing
• Mucosal destruction
• Shouldered margins

Rat tail appearance in esophageal carcinoma

Rings in esophagus

A ring
• Physiological contraction of smooth muscle covered by mucosa

B ring
Below B ring columnar
epithelium
Above B ring 
squamosal

Schatzkis ring
• Symptomatically narrow B ring
• Usually associated with hiatus hernia

A ring
B ring

Posterior cricoid web
• Plummer Wilson syndrome
• Predisposes to hypopharyngeal SCC
• More common in women
• Dysphagia
• Iron deficiency anemia
• Weight loss
• esophageal webs

Classical semilunar filling defect in esophageal
leiomyoma

Zenkers diverticulum
• Pharyngeal outpouch
• IOC  barium swallow

Diaphragm

Congenital eventration of diaphragm

Congenital diaphragmatic hernia

Pyloric stenosis

• a. Elongation and narrowing of pyloric canal (2–4 cm length)
• b. Passing of small barium streak through pyloric canal seen as a string of barium known
as string sign.
• c. Crowding of muscle folds in pyloric canal known as double/triple track sign.
• d. Transient triangular tent-like cleft/niche in mid portion of pyloric canal with apex
pointing inferiorly;
• e. Outpouching along lesser curvature due to disruption of antral peristalsis, known
aspyloric teat/teat sign.
• f. Mass impression upon antrum with streak of barium pointing toward pyloric channel,
known as beak sign/antral beaking.
• g. Indentation of the base of duodenal bulb known as umbrella/kirkling/ mushroom sign.
• h. Gastric hyperperistaltic waves known as caterpillar sign.
• i.Gastric distension with fluid.

• Ultrasound (investigation of choice)
• Criteria for diagnosis include
• 1. An elongated pyloric channel (longer than 16 mm),
• 2. An enlarged pyloric diameter (greater than 14 mm),
• 3. A thickened muscle wall (greater than 4 mm).

• The radiological
findings are
confirmatory and
consist of gastric
dilatation with a
deficiency of small-
bowel gas.

• HYPERTROPHIC PYLORIC STENOSIS
• Pyloric stenosis is the most common surgical disorder producing emesis in
infancy.
• It results from hypertrophy of the circular and longitudinal muscularis of the
pylorus and the distal antrum of the stomach with progressive narrowing of
the pyloric canal.
• hypocloremic, hypokalemic metabolic alkalosis

HPS is a/w erythromycin intake in neonatal
period

• Investigations
• USG  IOC

USG shows target sign in Hypertrophic pyloric
stenosis

• IMAGING STUDIES
• A positive upper GI series can include the following diagnostic signs:
• 1. Outlining of the narrow pyloric channel by a single “string sign” or “double
track” owing to folds of mucosa
• 2. A pyloric “beak” where the pyloric entrance from the antrum occurs
• 3. The “shoulder” sign, in which the pyloric mass bulges into the antrum
• 4. Complete obstruction of the pylorus.

String sign is seen in barium swallow in pyloric
stenosis

String sign  most specific sign

• Rx
• Ramstedt pyloromyostomy

Gastric carcinoma
• Depth can be assessed by Upper GI endoscopy

Gasless abdomen
• High obstruction (esophageal
atresia with out fistula)
• Acute pancreatitis
• Congenital diaphragmatic
hernia

Single bubble sign
• Obstrn proximal to pylorus
• In pyloric stenosis

Gastric ulcers

Benign ulcer Malignanat ulcer
• 95 % • 5%
• Distal stomach & lesser curvature • Fundus & proximal part of greater curvature
• Margins are smooth & rounded
• Not elevated / heaped up / beaded
• Irregular
• Heaped up & beaded
• Radiating folds  smooth & symmetrical & reach
up to edge of ulcer
• Distorted folds that donot reach up to edge
• Hampton’s line lucent line at orifice of ulcer Carman meniscus sign  large flat based ulcer with
heaped up edges that fold inward to tarp a lens
shaped barium collection

Hamptons line  benign ulcer

Carman meniscus sign in malignant gastric
ulcer
• A large flat based ulcer with
heaped up edges that fold
inwards to trap a lens shaped
barium collection that is convex
towards lumen

Trifoliate dudodenum d/t secondary duodenal
diverticula which occurs as a result of peptic ulcer

Pneumoperitoneum

Investigation in pneumperitoneum
• Best is CT
• Followed
• CHEST xray erect >>left lateral decubitus >> abdomen erect

Pneumoperitoneum
• Cupola sign
• Inverted v sign
• Falciform ligament sign
• Football sign
• Rigler sign

Air under diaphragm in pneumoperitoneum

Cupola sign
• Air outlines the median
subphrenic space overlying
lower thoracic vertebra
Cupola sign

Foot ball sign
• Air outlines the confines of
peritoneal cavity

Foot ball sign

Falciform ligament sign
• Air outlines confines of peritoneal
cavity

Inverted V sign
• Air outlines medial umbilical folds

Telltale triangle sign
• Triangular collection
insubhepatic region

Doges cap sign in pneumoperitoneum

Chialiditi syndrome
• Pseudopneumoperitoneu
m
• Interposition of transverse
colon b/w diaphragm &
liver

Small bowel

• First part of duodenum  triangular cap
• Jejunum is feathery
• Valvulae conniventus
• Distinguish small bowel from large intestine
• Featureless distal ileum
• Decreased valvulae conniventis
• Large intestine
• Haustartions present in colon
• valve of houston in rectum

Feathery jejunum due to valvulae connivant

Haustrations of colon

H type to fistula
• X ray

• Plain X ray chest, erect
• To detect pneumoperitoneum

Small bowel Large bowel
• Valvulae conniventes  feathery appearance in
jejunum
• Featureless ileum
• Central in location
• Haustrations + in large intestine

Valvulae conniventis  feathery appearance
of jejunum

Double bubble sign
• In duodenal
atresia
• Duodenum
• Stomach

Triple bubble sign
Triple bubble sign in Proximal Jejunal Atresia

Small bowel obstruction
• String of bead sign
• Step ladder sign
• Concretina effect (herring bone pattern)

String of beads
• When the small bowel is filled with a large amount of fluid, a row of
small gas bubbles may be trapped between the valvulae conniventes.
The row of gas bubbles is called the “string of beads” or “string of
pearls” sign and is seen on the decubitus or upright view of the
abdomen

String of pearls

• String of beads in radiology
• Fibromuscular dysplasia
• Small intestinal obstruction
• Varicose bronchiectasis
• c/c pancreatitis

Step ladder in air fluid levels

Herring bone pattern in in jejunal obstruction

Riglers triad in gall
stone ileus
• Gall stone near terminal ileum
• Small intestinal obstruction
• Pneumobilia

Intestinal obstruction in neonates

• CT scan is best investigation for small bowel obstruction

Pyloric stenosis Duodenal atresia Jejunal atresia Ileal atresia
Single bubble sign Double bubble sign Triplle bubble sign Multiple bubble sign

Ileal atresia
• Multiple air level in plain x ray
• Microcolon on barium enema
• Obstruction in barium meal
• Apple peel appearance

Meconeum ileus
Abdominal X ray • Dilated loops of SI
• Absence of air fluid levels d/t thick & viscous
enteric contents
• soap bubble appearance
• Entrapment of small bubbles of gas in thick viscous
meconium  ground glass appearance
Contrast enema study • Microcolon (d/t disuse)

microcolon

Soap bubble appearance of meconium ileus

intussusception

Radiological signs in intussusception
Plain film • Target sign  soft tissue lucency with concentric
area of lucency d/t mesenteric fat
• Meniscus sign crescent of gas shadow with in
colonic lumen that outlines apex of intussusception
Barium enema • Claw sign rounded apex of intussusception that
protrudes into contrast column
• Coiled spring sign  edematous mucosal folds of
returning limb of intussusceptum outlined by
contrast material
USG • Target sign
• Bull’s eye sign
• Pseudokidney sign
• Doughnut sign
CT scan • IOC
• Target sign may be seenTONY SCARIA 2010 KMC

Meniscus sign

Claw sign

Coiled spring sign

Target sign on USG

Bulls eye sign

Radiological findings
Plain x ray • Large inverted U shaped loop of massively
distended sigmoid colon  coffee bean sign or
bend inner tube
• Absent haustra
• Apex of loop reaching left diaphragm
Gastrograffin enema • Narrowing at site of volvulus  bird of prey sign
or ace of spades sign

Coffee bean sign

Absent haustrations
Apex at left
hemidiaphragm

Bird of prey sign

Midgut volvulus
• Cork screw sign
• Whirl pool sign

Cork screw sign in midgut volvulus

Whirl pool sign
Bowel rotates around its mesentry with mesenteric vessels creating whorls

Gallstone ileus
• Riglers triad
• Incomplete or complete small bowel
obstruction
• Gas within GB (pneumobilia)
• Ectopic gall stone

Apple core appearance in Ca colon

RADIOLOGICAL SIGNS OF CROHNS DISEASE
• Apthous ulcer  earliest
• Central flecks of barium surrounded by halo
• Rose thorn appearance
• String sign of kantor
• creeping fat on CT scan

Aphthous ulcer  earliest feature of crohns
disease

Rose thorn appearance

String sign of kantor

Prominent vasa recta in active crohns disease
 COMB SIGN

String sign of kantor CROHNS DISEASE

Radiological features of UC
• Earliest change is fine mucosal granularity
• Deep ulceration appear as ‘ collar-button’ ulcers.
• Loss of haustration in long standing disease colon become
shortened and narrowed.
• Polyp can be seen which may be due to post inflammatory polyp,
pseudopolyp, adenomatous polyps or carcinoma.
• Loss of haustral folds lead pipe or pipe stem colon

Earliest change is fine mucosal granularity

Thumb printing is also seen in UC d/t mucosal
edema

Colonic ischemia  thumb print sign

Ileocaecal TB

Radiological features of ileocaecal
tuberculosis
Sterlin sign rapid emptying of narrowed terminal ileum into shortened rigid obliterated caecum on
barium examination.
Thickened ileocaecal valve
Fleischner’s sign (inverted umbrella defect) wide gaping patulous ileocaecal immediately adjacent
terminal ileum
Deep fissures + large shallow linear/stellate ulcers with characteristic elevated margins.
Symmetric annular 'napkin ring' stenosis(purse string stenosis)
Widened ic angle (normal is 90*) it becomes obtuse

Saw tooth appearance in diverticulosis
• Ba enema is IOC for diverticulosis
• Not colonoscopy

Portal vein

Normal portal vein Doppler is red in colour

Red colour in portal vein  portal HTN

Biliary tract

Wall echo shadow sign (WES)
c/c calcific cholecystitis

Double barrel sign on USG
• In CBD obstruction dilation of CBD
 size of lumen becomes
comparable to portal vein
• Dilated CBD + portal vein = double
barrel

Pseudomembranous colitis

Focusedd assessment with sonograph for
trauma
• FAST

1.Subxiphoid
• pericardial effusion
• Left lobe of liver injury
2.Right upper quadrant
• Right liver injury
• Right kidney injury
• Morison pouch
• 3.Left upper quadrant
• Splenic injury
• Left kidney injury
4.Suprapubic region
• Bladder
• Pouch of douglas

eFAST (extended FAST)
• Left & right thoracic views to assess haemothorax & pneumothorax

Gas less abdomen
• In a/c pancreatitis
• High obstruction
• Ascites
• CDH

Protein losing enteropathy
In 111
transferrin
Tc 99m labelled
human serum
albumin
Tc 99m dextran

• Drugs causing radiopacity in plain xray abdomen
• Phenothiazine
• Salicylate
• Iron

Meckels scan
• Technitium (9)pertechnitate
scan
• Uptake & retention by heterotopic
gastric mucosa  outlines
diverticulum

Splenic rupture on xray
• Obliteration of splenic outline
• Loss of psoas outline
• Elevation of left hemidiaphragm
• Fracture of lower ribs on left side indendation of gastric outline
• IOC  blunt trauma abdomen in CECT

gastrointestinal tract radiology revison notes

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to gastrointestinal tract radiology revison notes

Similar to gastrointestinal tract radiology revison notes (20)

More from TONY SCARIA

More from TONY SCARIA (20)

Recently uploaded

Recently uploaded (20)

gastrointestinal tract radiology revison notes