This document provides an overview of various imaging modalities used in gastrointestinal surgery at the University of Alexandria, including plain x-rays of the chest, abdomen, and pelvis. It discusses normal anatomy and findings, as well as pathologies seen on barium swallow, barium meal, barium follow through, barium enema, oral cholecystography, percutaneous transhepatic cholangiography (PTC), endoscopic retrograde cholangiopancreatography (ERCP), T-tube cholangiography, and intraoperative cholangiography. Examples of findings for conditions like hiatal hernia, gastric and duodenal ulcers, gallstones, biliary strictures, and cholangiocarcin

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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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Plain X-ray Chest postero-anterior
view

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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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Normal plain chest x-ray PA veiw

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Plain chest x-ray PA veiw

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Plain standing x ray PA view showing
Free air under diaphragm

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Plain standing x ray PA view showing
Free air under diaphragm

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Air under diaphragm

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

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Congenital diaphragmatic hernia

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Plain abdomen x-ray

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Plain X-ray abdomen supine

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Plain X-ray abdomen standing

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Plain X-ray abdomen

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

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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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DD: renal & gall bladder stones

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Radio-opaque shadow of the
abdomen x ray

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Chronic panreatitis

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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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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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Plain x-ray abdomen & pelvis
showing distended colonic loops

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Ileo-ceacal valve

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Post operative adynamic ileus
•SupineSupine •ErectErect

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Sigmoid Volvulus

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Plain x-ray abdomen and pelvis
showing pneumatic tyre appearance

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Plain x-ray abdomen and pelvis
showing pneumatic tyre appearance

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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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Caecal volvulus

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Plain x ray abdomen & pelvis
showing double bubble sign

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Plain x-ray abdomen and pelvis
Foreign body

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Plain x ray abdomen showing
aeroblia

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Invertogram

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Barium swallow

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

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Pathologies by barium swallow

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Achalasia of the cardia

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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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Corrosive stricture

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Barium swallow showing Corkscrow
oesophagus

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Irregular filling defect mostly Cancer
oesophagus

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Oesophageal malignancy

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Oesophageal malignancy

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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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serpiginous filling defects in the
oesophagus Oesophageal
varices

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Barium swallow with outpouch of the
barium--Oesophageal diverticula

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Epiphrenic and Zenker’s diverticulum

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Oesophageal web

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Barium meal

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Barium meal

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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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Barium meal (Single & Double)

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

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Pathological findings in barium meal

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Hiatal hernia

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Barium meal in trendlenberg position
showing Sliding hiatal hernia

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Barium meal in trendlenberg position
showing Sliding hiatal hernia

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Barium meal in trendlenberg position
showing Sliding hiatal hernia

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Barium meal in trendlenberg position
showing paraoesophageal hiatal hernia

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Barium meal in trendlenberg position
showing paraoesophageal hiatal hernia

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Barium meal showing
paraoesophageal hiatal hernia

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Barrett’s oesophagus

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Benign gastric ulcer

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

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

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Hour glass deformity

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Normal duodenal cap and DU

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2 kissing duodenal ulcers

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Trifoliate deformity of DU

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Gastric tumors

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Malignant gastric ulcer

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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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Lintis plastica

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Pyloric filling defect of malignant
origin

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Pre-pyloric tumor

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Duodenal diverticulum

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

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Barium meal showing Soap dish
appearance

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Congenital hypertrophic pyloric
stenosis

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GOO by compression from outside

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GOO by pseudopancreatic cyst

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Volvulus of the stomach
•Organoaxial volvulusOrganoaxial volvulus •Mesenteroaxial volvulus

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Organo-axial volvulus

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Duodenal atresia

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Barium follow through

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Barium follow through

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

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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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Barium enema

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Normal barium enema filling phase

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Pathological findings in barium enema

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Transverse colon filling defect

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Transverse colon filling defect
(colonic malignancy)

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Cancer ascending colon

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

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Diverticulosis

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

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

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

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

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Rounded filling defect (polyps)

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Rectosegmoid polyps

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

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Intussusception

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Intussusception

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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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Types

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Oral Cholecystography (OCG)Oral Cholecystography (OCG)

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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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Oral cholecystography (OCG)Oral cholecystography (OCG)

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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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Gall stones in OCGGall stones in OCG

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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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Normal PTCNormal PTC

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CBD stone-PTCCBD stone-PTC

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

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PTC with iatrogenic injury of CHD
with biloma

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ERCP

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

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CBD stone-ERCP

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CBD stone-ERCP

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CBD stone-ERCP

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CBD stone-ERCP

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Multiple intrahepatic & extrahepatic
stones

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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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Stents insertion-ERCP

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T-tube cholangiogram

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Normal T-tube cholangiogram

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Normal T-tube cholangiogram

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CBD stone, T-Tube

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T-tube cholangiogram with CBD
stone

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CBD stone, T-Tube

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Transcystic IO cholangiogram

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Transcystic IO cholangiogram

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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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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

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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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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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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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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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Normal MRCP

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CBD stones-MRCP

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Klatskin tumor-MRCP

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Biliary injury-MRCP

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Liver imaging

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

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Hydatid cyst

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Imaging
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