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Similar to Small bowel imaging small bowel AIIMS .ppt
Small bowel imaging small bowel AIIMS .ppt
- 1. SMALL BOWEL IMAGING Candidate: ShivaniPahwa Moderator: Dr Sanjay Thulkar
- 2. Imaging Modalities • Xrays • Barium studies • CT • MRI • Angiography • PET • Sonography
- 3. Plain radiographs Initial investigationin casualty
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- 6. Barium Studies Indirect • Smallbowel follow through • Small bowel meal • Peroral pneumocolon • Reflux examination Direct • Enteroclysis (small bowel enema)
- 7. BMFT • Two types Conventional(radiographic) Fluoroscopic • Preparation Dulcolax-afternoon before study Abstain from food and drink in the morning Metoclopramide
- 8. BMFT C/I of Metoclopramide High grade obstruction H/O allergy Reduces lumen diameter ?disadvantage
- 9. BMFT • Barium suspension-40%-50% w/v • Limitations Underdistention spurious nodularity Low grade obstrn Early mural infiltrn MISSED
- 10. BMFT • Fluoroscopic FTafter double contrast UGI examn- AVOID • Double contrast follow through • Peroral pneumocolon • Retrograde small bowel enema • See through small bowel study
- 11. Small bowel followthrough Jejunum ileum Thickness of folds 2-3 mm 1-2 mm Diameter of lumen Upto 3 cm Upto 2 cm
- 12. Enteroclysis • Single contrast -28-42%Ba @ 75ml/min • Biphasic enteroclysis -Methylcellulose ,air -Maglinte method-50% w/v Ba -Harlinger method- 80% w/v Ba
- 13. Advantages of enteroclysis •Pylorus bypassed • Tests luminal distensibility • Induces hypotonia simultaneous display of all dilated loops • Completed in 20-30 min
- 14. Enteroclysis • Disadvantages -Discomfort ofintubation -technical problems High flow rate poor distension reflux into stomach & duodenum Low flow rate hypotonia,retarded progress
- 15. Enteroclysis Jejunum Ileum Folds perinch length 4-7 2-4 Thickness of folds 1-2 mm 1-1.5 mm Diameter of lumen Upto 4 cm Upto 3 cm Wall thickness 1-1.5 mm 1-1.5 mm
- 16. CT Enteroclysis Kloppel andcolleagues (1992) • Barium studies mucosal details • CT extraluminal abnormalities • CT Enteroclysis both
- 17. CT Enteroclysis Contrast agents Neutral •0.5% methylcellulose • Water • Low density Barium(VoLumen) • Polyethylene glycol Positive • 4 – 15% water soluble contrast • Dilute 6% Barium
- 18.
- 19. CT Enteroclysis Indications forneutral contrast No e/o obstruction on plain radiographs Unexplained GI bleed or anemia Staging of known Crohn’s disease Unexplained pain abdomen Alternate examination before/after capsule endoscopy
- 20. CT Enteroclysis -Positivecontrast
- 21. CT enteroclysis Indications forpositive contrast C/I to IV contrast Suspected recurrent small bowel obstruction inconclusive conventional studies Suspected small bowel disease inconclusive conventional studies Suspected obstruction H/O surgery H/O radiotherapy
- 22. CT Enteroclysis Fluoroscopic Phase Small balloon catheter (9 F Maglinte Minicatheter)-positioned distal to DJ flexure 0.3 mg glucagon IV Infuse 1.5L of water at 100 ml/min RCNA 2007
- 23. CT Enteroclysis CT phase 0.3 mg glucagon IV 1.5 L contrast @ 100 ml/min IV contrast 4ml/sec,150 ml Acquisition at 50 sec delay RCNA 2007
- 24. CT Parameters 40 channelCT Source :40 x 0.625 mm Reformat:2.0 mm @ 1.0 mm recon interval Neutral contrast window width = 360 HU window level = 40HU Positive contrast window width = 1200HU window level =200 HU
- 25. CT Enterography • PatientPreparation • Oral contrast 0.1% w/v Ba solution with sorbitol • Volume- 900 to 1800 ml over 30 min to 1hr • metoclopramide +/- • 1 mg glucagon (i/m,i/v)
- 26. CT Enterography-Scanning Techniques • Singlephase imaging -”Enteric phase” - 45 sec - esp for Crohn’s Ds & obstn • Multiphasic imaging for Obscure GI bleed 1. Arterial phase- 6 sec 2. Enteric phase- 20-25 sec 3. Delayed phase- 70-75 sec
- 27. MR Imaging Specific advantages Better evaluation of fistulas Evaluation of bowel distensibility multiphasic imaging MR fluoroscopy
- 28. Enteric Contrast Agents •Negative • Positive • Biphasic
- 29. Negative Contrast Agents •Super paramagnetic particles • Perfluorooctyl bromide • Ferumoxide oral suspension • Oral magnetic particles • Low signal intensity on T1 w and T2w
- 30. Advantages • Bowel wallthickening - T1w • Bowel wall enhancement • Inflammation in surrounding fat-T2w • Inter loop abscesses – more conspicuous
- 31. Pitfalls GI side effects-5-15% Imaging artefacts Cost Paradoxical High intensity if not homogenously distributed
- 32. Positive Contrast Agents Paramagneticsubstances- • Gadolinium chelates • Manganese ions • Ferrous ions • Natural substances-milk,oil,ice cream,green tea,blueberry juice
- 33. Pearls and pitfalls Demonstrate wall thickness well on T1w Inter loop abscesses shown well on T1w - abscess has low signal intensity on T1 High signal intensity in lumen- masks bowel wall enhancement or intraluminal masses after I/V contrast
- 34. Biphasic Contrast Agents •T1w – low signal intensity T2w- high signal intensity • Agents in use- -water -polyethylene glycol -low Hounsfield Barium
- 35. Technical issues • Enteroclysisvs enterography • Pulse sequences T2 w single shot HASTE True-FISP, balanced fast field echo T1 w contrast enhanced gradient echo sequences with fat supression- 2D or 3D
- 36.
- 37. Angiography • To detectObscure GI bleed,massive acute bleed • Selective catheterisaation of coeliac axis,SMA,IMA
- 38. Radionucleide studies • Acutelower GI bleed -Technetium 99 sulphur colloid -technetium 99 labelled RBC’s- better • Meckel’s diverticulum -Technetium 99 pertechnate • Inflammatory bowel disease -Indium 111 labelled WBC’s
- 39. Small bowel pathology Inflammatory Neoplastic miscallaneous
- 40. Tuberculosis Barium studies Firststage -accelerated transit -chicken intestine -precipitation of barium -crenated,spiculated contour -thick folds
- 41. Tuberculosis Second stage • Ulcerations+ Third stage • absent mucosal relief • Short ‘hour glass’ stenosis • Multiple strictures • Fixed, matted loops • Signs of malabsorption
- 42. IC tuberculosis • Fleischner/inverted umbrellasign • Napkin ring stenosis • Goose neck deformity • Purse string stenosis • Stierlin’s sign • String sign
- 43. USG • Extramucosal changes •Thickened bowel wall >5 mm - non-distended >3mm - distended • Pseudo-kidney • Club sign
- 44. Tuberculosis CT Mural thickeningof IC area- concentric Low density areas in bowel wall Skip areas Enlarged mesenteric lymph nodes -with central low attenuation areas Obstruction D/D- Crohn’s
- 45. Crohn’s Disease • Smallbowel involved in 80% • Diagnosis and evaluation of early disease -Barium studies -Colonoscopy • Advanced disease -CT -MRI
- 46. Crohn’s Disease Early disease •Smooth symmetrical thickening of mucosal folds • Coarse villous pattern • Aphthoid ulcers 1-3mm Two or more signs + Increased likelihood of Crohn’s
- 47. Crohn’s disease Intermediate disease •Obliteration,distortio n of mucosal folds • Stellate/rosethorn appearance • Linear ulcers ,retraction of mesenteric border • sacculation of redundant border
- 48. Crohn’s Disease Advanced disease •Deep linear ulcers/fissures • Pseudopolyps • Cobblestone / ulceronodular appearance • Anti mesenteric redundancy- disappears • Fat wrapping
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- 53. Adenocarcinoma • 40% ofmalignant small bowel tumors • Duodenum/proximal jejunum • Barium-narrowing
- 54. Adenocarcinoma Eccentric focalmass Asymmetric thickening metastasis lymph nodes mesentry
- 55. Lymphoma- NHL Barium Aneurysmal Constrictive Nodular Ulcerative Mesenteric Sprue endoexoenteric
- 56. Lymphoma –Non-Hodgkin’s CT Circumferential Cavitary Mesenteric Value in treatment planning & post- therapy follow up
- 57. Lymphoma-Hodgkin’s • Extremely rare •Barium -tapered,eccenteric narrowing -displacement of bowel loops by nodal mass
- 58.
- 59. Leiomyosarcoma Ileum (50%) jejunum (33%) Barium Separation of loops Ulceration, barium filled cavities Tethering Shape altered by compression
- 60. Leiomyosarcoma CT Bulky ,eccenteric lesion Calcification +/- Significant enhancement with IV contrast Metastasis to liver,omentum
- 61. Carcinoid • Appendix ,terminal ileum Barium Less than 2 cm- incidental submucosal nodule Mesenteric involvement- -crowding of folds -kinking of bowel wall -separation of loops -narrowing of lumen
- 62. Carcinoid CT desmoplastic rxn Mesenteric mass with curvilinear strands extending to bowel loops- stellate appearance Adenopathy Liver metastasis Calcification-50%
- 63. Somatostatin receptor scanning-Indium 111 pentetreotide
- 64. Metastasis Intraperitoneal Bowel Ovary Uterus Hematogenous Malignant melanoma-Bull’s eye/ target Bronchogenic ca Breast ca Local
- 65.
- 66. Imaging in SmallBowel Obstruction 20% of patients presenting with acute abdomen 1st investigation- plain radiographs
- 67. Enteroclysis –Method ofchoice Low grade/intermittent obstruction Unsuspected closed loop obstruction H/O laparotomy for malignancy Radiation enteropathy Strictures in Crohn’s ds
- 68. Enteroclysis –C/I Acute& complete or high grade obstruction Suspicion of strangulated obstruction Suspected perforation
- 69. CT Level ofobstruction Cause Method of choice in- Acute,complete obstruction Adynamic ileus Prolonged high grade obstruction Suspicion of strangulation Suspicion of inflammatory process
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- 76. Obstruction Inflammatory Gallstone ileus
- 77. Mesenteric Ischemia • Rapidradiographic evolution • Plain X rays -thickened valvulae conniventes -dilated gas filled bowel loops -thickening of bowel wall -thumbprinting-occassionally -air in intestinal wall/hepatic veins
- 78.
- 79. Mesenteric Ischemia-CT • Neutraloral & IV contrast • Arterial phase • Venous phase
- 80. Mesenteric ischemia-CT ThinAxial images- -proximal arterial patency Sagittal projection -to evaluate origin & proximal portion of mesenteric arteries -to identify anatomic variants Volume rendering-coronal/cor oblique -distal branches MIP -smallest branches
- 81. Mesenteric Ischemia Findings Boweldilatation Mesnteric edema Vascular changes
- 82. Mesenteric Ischemia Boweldilatation Bowel thickening >8mm transmural infarct - paper thin Bowel wall attenuation low density edema high density hge Pneumatosis/portomese nteric venous gas
- 83. Mesenteric Ischemia Abnormal enhancementpatterns delayed on early phase;persistent on late phase Complete absence of enhancement very specific very rare Hyperemia-good prognosis CT Angiography
- 84. Malabsorption Role of radiology To determine the cause Possible complications CT and MR-complementary Specific pattern Bacterial overgrowth syndromes Adult coeliac ds Adult CF ZES Short bowel synd
- 85. Modifications in Bariumtechniques • Enteroclysis – prefd • Balloon-kept in distal duodenum • Larger amt of barium (more than 300ml) • Faster injection • Early compression spot films reqd
- 86. Coeliac disease • Lumendilatation • Fold thickening • Less than 3 folds/inch -jejunum • 4-6 folds/inch -ileum jejunisation
- 87. Conclusion barium studies –still 1st line of investigation CT – can demonstrate extra-luminal abnormalities MR – upcoming,esp where repeated imaging is required and radiation issues are a concern
- 88.
Editor's Notes
- #8 1.Conventional-appearance of barium in caecum is indication for fluoroscopy to demonstrate terminal ileum but lesions are missed on overhead films.bowel loop overlap obscures lesions.
- #9 Metoclpramide is given 20 min before BMFT
- #10 Jejunum-seen with patient turned to right.final overhead view serves for orientation.mobility & pliability of loops also studied in compression.300 ml,600ml
- #11 FT is done before UGI examn if both are reqd as-1.240% w/v is used for UGIE & 40-50% for FT-these two don’t mix. 2.heavier barium suspension will sink into pelvic loops preventing adequate visualisation. 1 mg IV glucagon can be given for peroral pneumocolon
- #13 450 ml
- #18 Neutral=10-30 HU ,advantages of each
- #19 advantages
- #21 advantages
- #26 advantage in staging Crohn’s Disease sinus tracts and fistulae better seen
- #39 Tc FOR MECKEL’S- more accurate in paed age group 2.indium WBCs-good for follow up
- #45 1.Concentric IC mural thickening 2.low density areass in wall 3.skip areas 4.enlarged LN with low attenuation centre 5.obstn
- #50 1.Mural enhancement-target/double halo,mild homogenous enhancement,≥109 H has high correlation with ds activity 2.length of involvement-focal <5 cm;segmental 5-40 cm 3.wall thickening-moderate-4-9 mm,marked >10 mm 4.asym thickening 5.fibrofatty proliferation of mesentry 6.phlegmon & abscesses 7.fistulae & sinuses 8.perienteric/pericolic vascularity-Comb’s sign
- #53 1.Plain film-obstruction,soft tissue outline of mass,calcification,displacement of bowel,complications as necrosis/ulceration or perforation. 2.barium-BMFT is 33% sensitive,enteroclysis-90% 3.CT-normal wall-less than 3 mm,mucosal folds-2-3mm,no separation of loops
- #54 more than 3 cm-significant extra-intestinal component
- #56 1.aneurysmal-common,solitary,barium pools within lesion which has no recognizable mucosal pattern,more on anti-mesenteric border 2.constrictive-circumferential thickening with effacement of mucosal folds 3.nodular-submucosal process-diffuse,focal large intraluminal mass,-prone to intussuception 4.ulcerative-contrast leak,fistulae 5.mesenteric-displacement & compression of bowel loops,infiltration causing obstruction 6.sprue-bizarre mucosal pattern with edema,enlargement of folds & segmentation of barium 7.Endoexoenteric with excavation fistula formation
- #57 1.circumferential-long segment circumscribed soft tissue mass,dilated lumen/sausage shaped mass 2.cavitary-perforation into leaves of mesentery 3.mesenteric-contiguous spread from lymph nodes –lobulated mass encasing bowel-sandwich appearance
- #71 Closed loop obstruction;whirl-volvulus
- #72 Strangulation-circumferential wall thickening with increased attenuation 2.target sign 3.congestion/hgg in mesentry 4.pneumatosis intestinalis 5.ascites-suspicious
- #75 Radiation enteropathy-localised.m.c. due to adhesions,mural thickening,mesenteric fibrosis
- #79 Rapid radiog.raphic evolution,dilated loops,thick valvulae,thumbprinting
- #82 1.Wall thickening->8mm;paper thin wall in transmural infarction 2.dilatation 3.attenuation-low density=edema;high=hgg 4.pneumatosis 5.thrombus,embolus,vasculitis,dissection,aneurysm,venous thrombosis,low flow states
- #84 Chronic mesenteric ischemia-Ct angio->50% stenosis of artery in 2 of 3 major arteries