ABDOMINAL RADIOLOGY

Dr. Seamus Looby & Dr. Brian A. Hogan

Specialist Registrars in Radiology, Department of Radiology, Beaumont Hospital

 Imaging Techniques

 Plain Film of the Abdomen (PFA)

o Basic Anatomy
o Interpretation of the PFA

 PFA findings in specific disease processes

 Calcification seen on the PFA

 Erect chest radiograph (CXR)

 Contrast studies
o Barium Swallow
o Barium Meal
o Small Bowel Follow Through (SBFT)
o Barium Enema
o IVP

 Barium study findings in specific disease processes

 Ultrasound

 Computed Tomography (CT)

 Magnetic Resonance Imaging (MRI)

 Endoscopic Retrograde Cholangio-Pancreatography (ERCP)

 Positron Emission Tomography (PET)

IMAGING TECHNIQUES

Radiology is often used in the investigation of gastro-intestinal (GI) and urological

disease processes. Despite its often pivotal role in the management of patients, radiology
should never replace thorough clinical history taking and clinical examination. Likewise
radiographic images should only be interpreted with knowledge of the clinical setting.

The plain film of the abdomen (PFA) and the erect chest radiograph (CXR) are the
most common radiographs that the house physician will be expected to interpret on the
ward when dealing with an abdominal problem. Other imaging techniques such as GI
contrast studies, ultrasound, CT, magnetic resonance imaging (MRI), ERCP,
positron emission tomography (PET) and CT/PET are used in specific problem
solving situations.

PLAIN FILM OF THE ABDOMEN

The PFA and the erect CXR are the standard radiographs used in the investigation of the
acute abdomen. The KUB (Kidney, Ureters, Bladder) is an alternate name for the same
radiograph used when investigating urological problems. The radiograph should include
the dome of the diaphragm down to the hernial orifices. While the role of the plain
abdominal radiograph has somewhat diminished due to the emergence of other imaging
techniques, it still plays a valuable role in the initial investigation of the acute abdomen.

The PFA is also valuable in identifying abdominal calcification. A plain film is often
performed prior to contrast studies and is referred to as the ‘control’ film. The image
formed in the PFA relies on the same basic radiographic principles as described in the
thoracic and musculoskeletal radiology sections.

The standard PFA is taken with the patient supine. Occasionally further abdominal views
such as a left lateral decubitus or erect radiograph may be obtained to show free intra-
abdominal air or fluid levels. These films require close interpretation and should only be
sought in conjunction with a radiologist.
 PLAIN FILM OF THE ABDOMEN (PFA) – BASIC ANATOMY

Figure 1 Normal abdominal anatomy

1 Gas in caecum 8 Liver

2 Gas in descending colon 9 Transverse process of L1
3 Gas in stomach 10 Right psoas muscle
4 Gastric rugal folds 11 Left psoas muscle
5 Twelfth rib 12 Head of femur
6 Right kidney 13 Pubic symphysis
7 L2 vertebra 14 Right sacro-iliac joint
INTERPRETATION OF THE PFA

There are some basic rules regarding interpretation of the plain abdominal film.

Name
It is always important to ensure that the correct radiograph for the correct patient is being
viewed.

Sex
Some pathological processes may be commoner in either one of the sexes. Obviously the
genitourinary tracts also differ.

Age
Old or young? Different pathological processes may vary between those of different ages.

Date of investigation
Many radiographs may be present in the patients ‘X-ray bag’ and it is important that the
appropriate radiograph is being viewed. Previous radiographs are helpful for comparison.

Marker
The right or left side should be labeled on the plain abdominal film.

Position
A supine AP (anteroposterior) abdominal film is usually obtained. However, in cases of
suspected bowel obstruction an erect abdominal film can be helpful as it demonstrates
fluid levels. Occasionally decubitus views (left side down) may be performed to show
intraperitoneal free air.

Having completed these steps, it is now possible to systematically interpret the abdominal
film.

Hollow viscera
Fluid-filled bowel is not visible on the supine film. The bowel may be outlined by intra-
luminal gas. Gas outlining rugal folds in the epigastrium will help identify the stomach
(Fig.1&2). In the supine position gas will rise anteriorly to outline the body and antrum;
fluid will pool posteriorly in the fundus beneath the left hemidiaphragm giving the
‘gastric pseudotumour’ – not to be mistaken for a true mass (Fig.2).

The small bowel loops are located at the centre of the abdomen and should not exceed
2.5cm-3cm in calibre. Often very little of the small bowel is seen and it only becomes
evident when abnormal. As it distends valvulae conniventes may be seen.

In contrast, the large bowel loops form a characteristic configuration around the
periphery of the abdomen. The length of the colon varies between individuals and
varying amounts of gas and faeces are encountered. The circular mucosal folds
surrounding the large bowel, known as haustra, are incomplete and characteristic
sacculations. The normal diameter of the large bowel loops varies from <9cm for the
caecum to <5cm for the rest of the large bowel. The appendix is rarely seen, but
occasionally an appendicolith (calcified faecal material) may be seen predisposing the
patient to appendicitis.

Helpful findings used to distinguish small bowel and large bowel are listed in Table 1.
below.

Table 1. The distinction between small bowel and large bowel dilatation
Small bowel Large bowel
Haustra Absent Present
Valvulae conniventes Present in jejunum Absent
Number of loops Many Few
Distribution of loops Central Peripheral
Radius of curvature of loop Small Large
Diameter of loop 30-50 mm 50 mm+
Solid faeces Absent May be present
Grainger & Allison’s Diagnostic Radiology

Soft tissues
The solid organs are also visualized on the plain film to varying degrees (Fig.1&2). The
liver, kidneys and spleen are commonly seen and should be scrutinized for size, contour
or abnormal calcifications. The pancreas is not seen unless it is calcified (Fig.17). The
ureters pass near the tips of the transverse processes of the vertebrae and descend over the
sacroiliac joints. These areas should be examined for calcified densities which may
represent calculi. The diaphragm and the psoas muscles should also be seen and
assessed for symmetry.

Bones
The bones should be systematically examined. The lower ribs, the lumbar vertebrae,
sacrum, pelvis and the hips should be inspected for evidence of fractures, scoliosis,
degenerative disease, Paget’s disease, myeloma and osteoblastic or osteolytic lesions
associated with metastatic bone disease (see musculoskeletal tutorial).

Calcifications (Fig.14-20)
It is worth looking at the abdominal film for specific areas of calcification in specific
organs.
1. Calcification in the right upper quadrant may indicate gallstones.
2. Renal, ureteric and bladder calculi.
3. Vascular calcification (aorta, splenic artery, pelvic phleboliths).
4. Calcification crossing the spine at L1 may indicate chronic pancreatitis.
5. As mentioned, an area of calcification in the right lower quadrant may indicate an
appendicolith (seen in appendicitis in 10%).
6. Calcification in the genitourinary tracts (uterine fibroids, prostate etc.).
7. Calcified lymph nodes (a common finding in older patients).
 Figure 2 Upper abdominal anatomy

RK – Right Kidney LK – Left Kidney

RP – Right Psoas LP – Left Psoas
SP – Spleen ST – Stomach with rugae
L – Liver (red arrowheads outline
the gastric ‘pseudotumour’)

Abnormal intra-abdominal gas

While the erect chest radiograph is primarily used to identify free intraperitoneal gas the
PFA may also identify free air. Gas outlining both sides of the bowel wall (Rigler sign)
and gas trapped under the falciform ligament are the main findings. The lateral decubitus
film may replace erect films when looking for free intraperitoneal air or air/fluid levels in
the bowel. Retroperitoneal free air may be seen to outline the kidneys. Air in the biliary
tree and portal vein can also be seen in some cases in the right upper quadrant. All these
findings may be subtle and are best interpreted by a radiologist.
PLAIN FILM FINDINGS IN SPECIFIC DISEASE PROCESSES

Dilatation of bowel
Dilatation of the bowel occurs in mechanical intestinal obstruction and adynamic or
paralytic ileus. Mechanical bowel obstruction occurs whenever there is an intrinsic or
extrinsic blockage of bowel contents. Prompt diagnosis and institution of optimal
treatment is paramount to a good outcome. Taking a good clinical history and thorough
clinical examination are key. The PFA assists in the diagnosis and helps distinguish small
bowel obstruction from large bowel obstruction and adynamic ileus. The radiological
differentiation of these different causes depends mainly on the size and distribution of the
loops of bowel (Table 1).

Small bowel obstruction

The classic symptoms of small bowel obstruction include crampy abdominal pain,
bloating, nausea, vomiting and decreased stool output. Examination may reveal
distension, abdominal tenderness, peritoneal signs and high-pitched bowel sounds. The
commonest causes are adhesions caused by previous abdominal surgery or peritonitis and
herniae. Other causes include neoplasms, inflammation secondary to Crohns disease,
appendicitis or TB, intussusception, gallstone ileus, intestinal ischaemia and radiation
treatment.

Figure 3 Supine PFA. Large

quantities of gas within
distended loops of small bowel
identified by its central position,
multiple loops and valvulae
conniventes.
Gas proximal to the obstruction represents swallowed air and may be relieved by passage
of a nasogastric tube. More than two gas-fluid levels in the small bowel on an upright
film (Fig.5) is generally considered abnormal. The presence of gas-fluid levels at
different heights in the same loop is considered good evidence of a mechanical
obstruction, but may occasionally be seen in adynamic ileus.

Figure 4 Gas within the lumen of

the bowel outlines the valvulae
conniventes (arrows), which
completely encircle the bowel.

Figure 5 Erect PFA.

Distended small bowel
with several air/fluid
levels (arrows).
Large bowel obstruction
The symptoms of large bowel obstruction include abdominal pain, bloating and nausea.
Vomiting is not as common as in small bowel obstruction initially, but may become a
feature as the obstruction becomes long-standing. Constipation is a commoner feature
than in small bowel obstruction. Absolute constipation where no faeces or flatus is passed
per rectum is quite specific for large bowel obstruction. Examination may reveal
distension, abdominal tenderness, peritoneal signs and high-pitched bowel sounds.

Most small bowel obstructions are caused by adhesions; in colonic obstructions,

adhesions are rarely the cause. The commonest causes include primary tumour of the
colon and inflammatory strictures from diverticulitis, inflammatory bowel disease, TB,
parasitic disease and ischaemia. Other causes include herniae, volvulus, Hirchsprung’s
disease, adhesions, extrinsic lesions (neoplasms, abscesses, endometriosis), faecal
impaction and Ogilvie’s syndrome (idiopathic megacolon seen in the elderly or in
patients with psychiatric disease).

Figure 6 Supine PFA.

Gas-filled, distended
large bowel seen
peripherally ‘framing’
the abdomen (arrows).
Competent ileocaecal
valve results in no
small bowel dilatation.
 Figure 7 Erect PFA.
Large bowel obstruction
with air/fluid levels
(arrows).

Volvulus
Volvulus refers to a ‘closed loop’ bowel obstruction whereby a segment of bowel twists
on its own mesentery. Volvulus of the large bowel is the third most common cause of
colonic obstruction. Predisposing factors include redundant loops of bowel, elongated
mesentery and chronic colonic distension. Sigmoid volvulus accounts for 80% of cases
of colonic volvulus and is commoner in men. A long redundant loop of sigmoid colon
can undergo a twist on its mesenteric axis and form a closed-loop obstruction. The
characteristic plain film findings (Fig.8) are of a massively dilated segment of sigmoid
colon, devoid of haustra and in a characteristic coffee bean shape, with both ends in the
pelvis and the apex lying under the left hemidiaphragm.

Figure 8 Sigmoid volvulus

Massively distended gas-
filled loops of sigmoid
colon (black arrows). The
characteristic coffee bean
shape is seen with the
apposing walls of the two
limbs in contact with each
other (white arrows).
Contrast from a recent i.v.
contrast examination such
as an IVP or CT is seen in
the urinary tract.
Caecal volvulus is far less common and tends to occur moreso in women and younger
patients. The distended caecum tends to be displaced upward and to the left (Fig.9). The
ascending colon and caecum may have a long mesentery predisposing it to volvulus with
the caecum twisting on its long axis. Colonic ileus, distal obstruction, pregnancy and
chronic faecal retention have been implicated as precipitating causes.

Figure 9 Supine PFA shows the

massively dilated caecum in the
left upper quadrant. The asterix
marks the normal position of
the caecum. Dilated loops of
small bowel are also seen
(arrows).

Figure 10 A magnified image of

the same patient as above with
caecal volvulus. The gas filled
appendix (arrow) is seen in the
left upper quadrant.
Adynamic or paralytic ileus
Adynamic ileus is a disorder of intestinal motor activity. The clinical appearance ranges
from minimal symptoms to generalized abdominal distension. Complete absence of
bowel sounds over a three-minute period indicates adynamic ileus (complete absence of
peristalsis in a paralyzed bowel). It occurs to some extent in almost every patient who
undergoes abdominal surgery. It is postulated that drying of the bowel, excessive
handling or change in temperature during surgery may be responsible. Other causes
include peritonitis, medications e.g. morphine, barbiturates and L-dopa, electrolyte
imbalance e.g. hypokalemia, hypomagnesemia and hypocalcemia, endocrine disorders
e.g. hypothyroidism, abdominal trauma and gram negative septicaemia.

Thumbprinting of the colon

Thumbprinting of the colon (Fig.11&12) is a plain film finding indicative of colitis. The
characteristic finding is of sharply defined thumbprint like indentations along the wall of
the colon. Thumbprinting is due to oedematous haustral folds which are thickened and
outlined by the gas in the distended lumen. Ulcerative colitis is by far the commonest
cause. Other causes include Crohns disease, ischaemic colitis, pseudomembranous colitis
and other infectious colitides.

Figure 11 Supine PFA

showing
thumbprinting
(arrows) in a patient
with an acute
exacerbation of
ulcerative colitis.
Toxic megacolon
Toxic megacolon is characterized by extreme dilatation of a portion of colon or entire
colon combined with systemic toxicity. The commonest cause is ulcerative colitis. Other
causes include Crohns disease, pseudomembranous colitis, ischaemic colitis and
infectious colitis. The patient is usually very ill with abdominal pain and tenderness,
tachycardia, fever and leucocytosis. The prominent dilatation (>6cm) is seen in the
transverse colon. Thumbprinting, dissection of gas into the bowel wall and free
intraperitoneal air may also be seen.

Figure 12 Toxic megacolon

with thumbprinting (arrow)
in a patient with an acute
exacerbation of ulcerative
colitis
 Figure 13 Ischaemic
colitis with dilatation of
the transverse colon and
gas in the wall of the
descending colon
(arrows) indicative of
bowel infarction.

CALCIFICATIONS SEEN ON THE PFA

The PFA is also helpful in identifying intra-abdominal calcification which appears as an
opacity on the film. The position, size, contour and density can help in identifying the
source of the calcification and suggest whether it is likely to be a significant finding.
Calcification can occur in virtually any organ including the kidneys and urinary tract, the
liver, gallbladder, spleen, pancreas and both the male and female genital tracts. The
calcification may be due to calculi (gallstones, urinary tract), infection (TB,
histoplasmosis, schistosomiasis), benign tumours (fibroids, leiomyomas), malignant
tumours (mucinous carcinoma of stomach or colon), haematoma, metabolic disorders or
may be vascular in nature (arterial, phleboliths). There are many other miscellaneous
causes of abdominal calcification.
 Figure 14 Right-sided
staghorn calculus.
Approximately 80% of renal
calculi are opaque. Urinary
stasis and infection are
important predisposing
factors. Patients may
complain of renal colic and
haematuria.

Figure 15 Calcified
gallstone in the right upper
quadrant. Approximately
20% of gallstones are
radiopaque. They may be
single or multiple, smooth
or faceted and may be
laminated. Ultrasound,
MRCP and ERCP are better
investigations for
visualising gallstones and
the biliary system.
 Figure 16 A view of
the right upper
quadrant shows both
renal calculi (arrows)
and a laminated
gallstones
(arrowheads).

Figure 17 Calcification occurs in 20% to 40% of patients

with chronic alcoholic pancreatitis. 90% of patients with
pancreatic calcification have high alcohol intake.
 Figure 18 Abdominal
Aortic Aneurysm
Atherosclerosis in elderly
patients often causes arterial
calcification. The walls of
aneurysms also often calcify
as seen here (arrowheads).

Figure 19 PFA in a 39
week pregnant woman with
ulcerative colitis. The film
was performed to outrule
toxic megacolon. Usually
radiological procedures are
avoided in pregnancy to
protect the developing
foetus.The foetal head is
seen in the mother’s pelvis
(arrowheads). The ribs,
spine and limbs are also
seen.
Figure 20An IVC filter
(arrowhead) is seen in good
position below the level of the
renal veins. Non-pathological
calcifications frequently seen in
the pelvis are phleboliths. These
are small calcified venous
thrombi often seen along the
lateral walls of the pelvis. Almost
all adults have a few of them.

Figure 21 Magnified view

showing phleboliths (arrows) of
various sizes.
 Figure 22 Nasogastric (NG)
tubes (arrow) are commonly
seen on in-patient
radiographs. Vascular stents,
in this case a right iliac
arterial stent, are also
sometimes encountered
(arrowhead).

Figure 23 A female patient

with bilateral tubal ligation
clips (black arrows) and an
intrauterine contraceptive
device (white arrow).
Figure 24 Cocaine
‘Body Packer’
Calcifications are not
the only densities seen
on PFA. Swallowed
substances such as
tablets and in this case
smuggled capsules of
cocaine may also be
seen.
ERECT CHEST RADIOGRAPH (CXR)

An abdominal film is rarely obtained in isolation in the setting of the acute abdomen. The
erect chest radiograph may demonstrate free air under the diaphragm indicative of bowel
or other organ perforation, as well as reveal chest diseases (pneumonia, pulmonary
infarction, myocardial infarction etc.) that may mimic an acute abdomen. Free gas is best
demonstrated by examination of the patient in the upright position. Because the gas
ascends to the highest point in the peritoneal cavity, it accumulates beneath the domes of
the diaphragm (Fig).

Figure 25 Erect CXR showing free air below both domes of the diaphragm (arrows). The
normal gastric bubble is also shown. Free air is normally best seen on the right between
the solid liver and the right hemidiaphragm.

It is important to notice that it is an erect CXR and not an abdominal film that is most
helpful in showing subdiaphragmatic free air. Pneumoperitoneum associated with
significant abdominal pain and tenderness is often caused by perforation of a gas-
containing viscus and indicates a surgical emergency. The most frequent cause of
pneumoperitoneum with peritonitis is perforation of a peptic ulcer, either gastric or
duodenal. Colonic perforation due to obstructing malignancy, toxic megacolon and
diverticulitis also may cause pneumoperitoneum.
Pneumoperitoneum rarely occurs due to perforation in appendicitis, a Meckel’s
diverticulum and cholecystitis. Other causes include gas-forming bacteria, penetrating
injuries, iatrogenic causes (laparotomy, laparoscopy, peritoneal dialysis, perforation
during endoscopy), ascent of air through the female genital tract and through a
diaphragmatic defect.

Figure 26 Another erect

CXR showing more obvious
intraperitoneal free air.

Figure 27 Erect CXR

showing massive
intraperitoneal free air.
CONTRAST STUDIES

The soft tissue density of the abdominal organs is similar to that of water. Therefore they
are usually not visible unless outlined by fat or adjacent gas. Because of this intrinsic lack
of contrast in the abdomen, radio-opaque contrast media are introduced to show up
various organs. Barium studies, intravenous urograms (IVUs) and angiograms are
contrast studies.

Barium is a relatively cheap contrast agent that is used to opacify the gastrointestinal tract
during radiological procedures. It is a positive contrast agent as it absorbs x-rays and so
is radiopaque. It may be used on its own in a single contrast study or with gas in a
double contrast study. Gas can be pumped into the bowel or released by gas producing
granules to act as a negative contrast agent. It does not absorb x-rays and so is
radiolucent. In a double contrast study the barium is used to line the mucosa and gas is
used to fill the lumen thus giving a double contrast effect.

A major complication of barium studies occurs if the barium escapes into the peritoneal
cavity. This may occur in perforation or in leaks following surgical procedures. It will
produce pain and severe hypovolaemic shock. Despite treatment there is a 50% mortality
rate and of those who survive 30% will develop adhesions. Water-soluble contrast media
may be used safely in situations where perforations or leaks are suspected.

Barium Swallow
A barium swallow is a radiological investigation of the oesophagus whereby the patient
swallows a mouthful of effervescent granules followed by a mouthful of barium contrast.
A double contrast effect of gas and barium is created within the oesophagus and a series
of x-ray exposures are obtained as the barium travels from the oropharynx to the
stomach.

Despite the widespread application of upper GI endoscopy barium studies still play a
vital role in the investigation of oesophageal pathology. It also has the advantages of
being relatively non-invasive, easily tolerated by patients and not requiring sedation. It is
performed for the investigation of dysphagia and odynophagia and is invaluable in the
diagnosis of oesophageal carcinoma, strictures, diverticulae, ulceration and motility
disorders.
Figure 28 Figure 29 Figure 30

Figure 28 Normal AP view of the cervical

oesophagus from a barium swallow.
Figure 29 AP view of the thoracic oesophagus
showing the normal impression on the left side
of the oesophagus of the aortic arch (white
arrow) at the T4 level. The black arrow points to
the oesophago-gastric junction. Note the double
contrast effect of the barium lining the mucosa
with air in the lumen.
Figure 30 Oblique view of the thoracic
oesophagus showing the normal extrinsic
impression of the aortic arch (arrow).
Figure 31 Lateral view of the cervical
oesophagus showing the normal extrinsic
impression of the pharyngeal venous plexus.

Figure 31
 Figure 32 Achalasia
Achalasia is a disease characterized by
incomplete relaxation of the lower oesophageal
sphincter due to destruction or absence of
ganglion cells in the myenteric or Auerbach’s
plexi in the distal oesophagus. This causes
progressive dilatation and tortuosity of the
oesophagus with incoordination of peristalsis.
The main symptoms are dysphagia, chest pain,
regurgitation and halitosis. Recurrent episodes
of pneumonia due to aspiration may be the
presenting feature.
The CXR, as well as showing evidence of
aspiration pneumonia, may reveal a widened
mediastinum, often with an air-fluid level,
produced by a dilated residue-filled
oesophagus. The characteristic barium swallow
findings are of a dilated oesophagus with a
smoothly tapered, conical narrowing of the
distal oesophagus, the so called beak sign.

Figure 33 Oesophageal carcinoma

Irregular circumferential lesion with mucosal
destruction, oesophageal narrowing with
shouldering and abrupt transition to adjacent
normal tissue. Flat plaquelike lesions and
less frequently, polypoid masses with
ulceration and a fungating appearance are
also encountered.
Oesophageal carcinoma is a major cause of
dysphagia in patients older than 40. There is
a close association with drinking and
smoking and with head and neck carcinoma.
Other associations include achalasia and
Plummer-Vinson syndrome.Weight loss and
anorexia are common features. It spreads
rapidly and often ulcerates. Most are
squamous cell carcinomas with
adenocarcinoma being associated with
Barrett’s oesophagus.
 Figure 34 Hiatus hernia
The stomach has herniated
through the oesophageal hiatus
(arrow). The proximal stomach is
seen as a barium filled dilatation
above the diaphragm in the
thorax. Most hernias (80%) are
sliding in nature and herniate
directly while 20% are
paraoesophageal and are pushed
up alongside the oesophagus. It is
often associated with oesophageal
reflux disease.

Figure 35 Erect CXR

shows a huge air-filled
hiatus hernia with an air
fluid level that appears
as a retrocardiac mass.
Barium Meal
A barium meal is a non invasive radiological investigation of the stomach, it has largely
been superceded by OGD. It is a double contrast study. The aim of the study is to distend
the stomach and duodenum with gas after coating the mucosa with a thin, even layer of
barium. A series of x-ray exposures are obtained with the patient lying in different
positions to coat the gastric and duodenal mucosa with barium and distend them with gas.

Gastric ulcer
A gastric ulcer is part of the spectrum of peptic ulcer disease. It is usually diagnosed by
OGD. However, on a barium meal it has the appearance of a ring shadow of barium
surrounded by thickened folds. Irregular folds merging into a mound of polypoid tissue
around the crater suggest a malignant ulcer. All gastric ulcers should be biopsied to
exclude carcinoma.

Gastric carcinoma
There is a spectrum of barium meal appearances for gastric carcinoma. Ulcers vary from
shallow erosions in superficial mucosal lesions to huge excavations in fungating polypoid
masses. Gastric filling defects and narrowing of the stomach are other common features.
Symptoms include dyspepsia, weight loss, vomiting, dysphagia, maelena and
symptoms of anaemia.

Figure 36 Gastric
carcinoma as a large
irregular filling defect
(arrowheads) in the
stomach. An area of
ulceration has filled with
barium (arrow). The
normal mucosal and
rugal fold pattern is
destroyed. There is a
strong association with
H.pylori infection.
 Figure 37 Linitus plastica
The ‘leather bottle’ appearance of linitus
plastica can also be seen in gastric
carcinoma. It is due to thickening and
fixation of the stomach wall, which usually
begins near the pylorus and progresses
upwards. This is difficult to diagnose on
OGD. In a barium meal study the stomach is
narrowed and non-distensible on all views.
Normal peristalsis is absent. Gastric
carcinoma can also cause segmental
narrowing.

Figure 38 Duodenal ulcer

Peptic ulceration can also affect
the proximal duodenum. They
cause epigastric pain, often
relieved by eating, and
waterbrash. The chief dangers are
gastro-intestinal bleeding and
perforation. A barium filled ulcer
is seen in the duodenum (arrow).
Small Bowel Follow Through (SBFT)
A small bowel follow through examination is an investigation of the small bowel. It is
used in the investigation of suspected small bowel disease such as Crohns disease, TB
and malignancy. It is indicated in the investigation of abdominal pain, diarrhoea,
recurrent upper GI bleeds and iron deficiency anaemia, unexplained weight loss,
malabsorption, partial obstruction and radiation change.

Following a bowel preparation (which usually consists of fasting for 8 hours and a
laxative), the patient ingests 500-600 mls of a diluted barium mixture and is therefore a
single contrast study. A series of x-ray images are obtained every 5-10 minutes until
barium reaches the caecum.

An alternative to this investigation is a small bowel enema or enteroclysis. In this

investigation, the small bowel is intubated with a nasogastric tube and barium is directly
delivered to the small bowel thus allowing for better mucosal definition.

Figure 39 Normal SBFT

showing the stomach (1)
with normal gatric rugae,
the normal fluffy
appearance of the jejunum
(2) in the left upper
quadrant and the more
tubular appearing ileum (3)
in the right lower quadrant.
 Figure 40 It is very important
to see the terminal ileum
(white arrows) where it enters
the caecum (C) on a SBFT as
it is often involved in diseases
such as Crohn’s and TB. Note
the normal appendix (black
arrow).

Figure 41 Crohn’s disease

This chronic inflammatory disorder may
affect any part of the gut, especially the
terminal ileum (opposite), colon and the
anorectum, with ulcers, fistulae and
granulomata. Clinical features include
cramping abdominal pain, weight loss,
diarrhoea, subacute GI obstruction and fever.
Anal and perianal lesions are common. The
characteristic barium study findings include
strictures, ‘rose thorn ulcers’ (arrows) and
‘cobblestone’ mucosal surfaces. The
cobblestone effect can be seen opposite with
the dark areas representing islands of normal
mucosa and the white linear areas
representing barium in linear ulcers.
Figure 42 A SBFT examination in a
patient with Crohn’s disease who has
had a right hemicolectomy, therefore
the small bowel enters the transverse
colon (T). Normal jejunal (J) and ileal
(I) bowel folds are seen. The distal
ileum is diseased showing the
characteristic ‘string sign’ (white
arrows) resulting from small bowel
narrowing due to marked wall
thickening. The separation of this
abnormal loop from other parts of the
small bowel is indicative of the marked
wall thickening

Figure 43 A magnified view of the

distal ileum shows the ‘string sign’,
ulceration and cobblestone mucosal
(arrows) of Crohn’s disease.
Barium Enema
The double contrast barium enema study is used to investigate the large bowel. It has the
advantages of being relatively cheap and uncomplicated but it has the disadvantages of
not detecting small polyps. It is still frequently used despite colonoscopy and CT
colonoscopy. It is indicated in the investigation of change in bowel habit, iron deficiency
anaemia, bleeding per rectum, weight loss, tenesmus and as a screening tool in patients
with a history of familial polyposis syndromes. It should not be performed in patients
with a suspected colonic perforation, toxic megacolon or severe colitis or following
recent colonic biopsy.

The bowel preparation for a barium enema consists of clear fluids only in the preceding
24 hours with morning and evening laxatives. A tube is inserted into the patient’s rectum
and 500-700 mls of diluted barium is instilled until the barium reaches the caecum. Air is
administered via a pump. A double contrast effect is created with air and barium. The
patient moves into different positions and different images are obtained of the large
bowel.

Figure 44 Normal erect

barium enema anatomy
showing the haustral folds
(black arrows). Barium
(positive contrast) is seen
in the dependent areas,
while air (negative
contrast) moves
superiorly. Incidental note
is made of a diverticulum
(white arrow).

1 Ascending colon
2 Caecum
3 Descending colon
4 Splenic flexure
5 Rectum
6 Hepatic flexure
8 Sigmoid colon
 Figure 45 Diverticular
disease
A diverticulum is an
outpouching of the wall of the
gut. The term diverticulosis
means that diverticula are
present, whereas diverticular
disease implies they are
symptomatic. Diverticulitis
refers to inflammation within
the diverticulum. Symptoms
include altered bowel habit,
abdominal pain, nausea and
flatulence. In diverticulitis
there may be localized or
generalized peritonitis and
fever. Haemorrhage may
occur and is usually sudden
and painless. Multiple
divertula are shown opposite.

Figure 46 An adenomatous polyp (arrows) may be sessile or pedunculated and have

a stalk (small arrows) as above. They are premalignant and may be single, multiple
or part of a familial polyposis syndrome. Polyps are carcinomatous until proved
otherwise and the likelihood of this increases with increasing polyp size.
Figure 47 A double contrast
barium enema in a patient
with Crohn’s disease
showing typical skip lesions
(arrows) separated by
normal colonic mucosal.

Figure 48 A magnified
image showing colonic
narrowing caused by an
asymmetric stricture. Note
the characteristic rose thorn
ulcers (arrows).
Figure 49 Colonic Carcinoma has various appearances including saddle lesions,
polyps and annular constricting lesions as above. This is known as an applecore
lesion with mucosal shouldering (arrows). They may cause ulceration.
Predisposing factors include polyps, ulcerative colitis (and to a lesser extent
Crohn’s disease), family history, familial polyposis syndromes and previous
cancer. Symptoms include bleeding per rectum, altered bowel habit, tenesmus,
weight loss, anaemia, an abdominal mass and pain. Metastatic spread is local,
lymphatic, haematogenous (liver, lung, bone) and transcoelomic.
Intravenous Urogram (IVU)/ Pyelogram (IVP)

Figure 50 IVPs are indicated in

suspected urinary tract
pathology. It involves the
injection of approximately
70mls of iodine based
intravenous contrast, which is
excreted by the kidneys. Several
exposures are taken through the
study to assess the urinary tract
anatomy. A 20 minute film
from an IVU showing normal
calyces (C), renal pelvis (P),
ureters (U) and bladder (B).

Figure 51 A delayed film

from an IVU in a patient
with a known bladder
tumour. There is a
persisting nephrogram
(RK), hydronephrosis with
a dilated pelvicalyceal
system (PC), hydroureter
(HU) and a filling defect in
the bladder (BT) due to the
bladder tumour.
ULTRASOUND
An abdominal ultrasound is a useful modality in the investigation of the solid abdominal
organs. Indications for an abdominal ultrasound include investigation of localized
abdominal pain, jaundice, abdominal masses, organomegaly, abnormal liver or renal
function, suspected aortic aneurysm and suspected malignancy. It is also useful in
investigation the female reproductive system.
It offers the advantages of being safe, easy to perform, non invasive and, in most
hospitals, it is readily available. It does not involve the use of any radiation and so can be
readily used in all patients including children and pregnant women.
The only preparation necessary for abdominal ultrasound is fasting for 4 hours so as to
distend the gall bladder and make it readily visible.

Figure 52 Ultrasound is the primary investigation for the gall bladder and biliary
system. In the normal patient the gall bladder (GB) is uniformly dark and thin
walled. If the gall bladder is not seen then the patient has either had a
cholecystectomy, is not fasting or the gall bladder is contracted. The adjacent
structures such as the liver, spleen, portal vein (PV) and common bile duct (CBD)
are also scanned as part of an abdominal ultrasound study. It demonstrates the
intra and extrahepatic ducts and can diagnose biliary obstruction. The common
bile duct is seen to lie anterior to the portal vein. It is measured at the level of the
hepatic artery. A common bile duct diameter of 3-6mm is accepted as normal with
1mm per decade added to patients >60. If there is an obstruction present, the level
and the cause of the obstruction can sometimes be identified. The common causes
include gallstones in the common bile duct, benign strictures within the common
bile duct, pancreatic carcinoma, cholangiosarcoma and lymph nodes in the porta
hepatis, which may be inflammatory or malignant.
 Figure 53 Ultrasound is
95% specific in the
diagnosis of gallstones.
The diagnosis is made by
demonstrating echogenic
or bright foci (black
arrows) within the gall
bladder (GB), which have
posterior shadows (white
arrows) and are mobile.
Ultrasound is used to
diagnose acute
cholecystitis. The typical
findings are of gallstones
or biliary sludge, a
thickened gall bladder
wall and a sonographic
Murphy’s sign i.e. the
patient is tender in the
right upper quadrant
following compression
with the ultrasound
transducer.

Figure 54 Further
ultrasound views of
the liver show the
IVC entering the
heart and the left
hepatic vein (LHV)
draining from the
left lobe of the liver
(LLL).
 Figure 55 Ultrasound is often used
to assess the kidney. Renal calculi,
hydronephrosis, scars, cysts,
abscesses, tumours and perinephric
collections can all be seen with
ultrasound. Renal size, contour and
echogenicity can be recorded. A
normal ultrasound of the right
kidney (kidney) is shown with a
non-dilated pelvicalyceal system
(PC).

Figure 56 Moderate hydronephrosis

Note the dilated pelvicalyceal system
(arrows) when compared to the
pelvicalyceal system in Fig.55. The
cortex is well maintained.

Figure 57 Gross hydronephrosis

in a renal transplant showing
dilated calyces (C) and renal
pelvis (P). There is marked
thinning of the cortex.
COMPUTED TOMOGRAPHY (CT)

A CT abdomen is a three dimensional radiographic view of the abdominal structures. It

carries the disadvantage of a high radiation dose. However, it allows for better
visualization of the abdominal structures and can help in the diagnosis of malignancy,
inflammatory diseases, abscesses, infectious diseases, abdominal aortic aneurysms and
many other disease entities. It is often used in the rapid assessment of trauma patients
with suspected intra-abdominal injuries.
Oral and intravenous contrast is used to improve visualization of the bowel, vascular
structures and the abdominal organs. Before a patient receives intravenous contrast, it is
important that a history of renal disease and allergies is obtained as the iodine based
contrast used in radiology is both nephrotoxic and may cause allergic reactions and even
anaphylaxis.

Figure 58 Dynamic (with i.v.contrast) axial CT of the upper abdomen showing a left
renal tumour (red arrow) and normal anatomy (white arrows – splenic vein, black
arrows – left renal vein). Note that the i.v. contrast has caused the vascular structures
and abdominal organs to enhance or to become brighter.

AO Aorta IVC Inferior vena cava

GB Gallbladder LIV Liver
LK Left Kidney RK Right Kidney
SB Small bowel loops
Figure 59 Dynamic axial CT of the mid abdomen showing a left renal artery
aneurysm (black arrows) rupture with haematoma (red arrows) in the
retroperitoneum displacing the left kidney anteriorly.

AO Aorta AC Ascending colon

ES Erector spinae LK Left Kidney
RK Right Kidney SMA Superior mesenteric artery
S Spinal cord SMV Superior mesenteric vein
V Vertebra TC Transverse colon
Figure 60 Axial dynamic CT of a female pelvis showing a left ovarian tumour (white
arrow) with areas of calcification within it (black arrows). The tumour was a
teratoma and the calcifications were primitive teeth.

BL Bladder LIP Left iliopsoas muscle

RA Rectus abdominus RIP Right iliopsoas muscle
UT Uterus REC Rectum
SAC Sacrum
MAGNETIC RESONANCE IMAGING (MRI)

MRI is a form of radiology that uses magnetic fields and gradients to provide images of
the patient. It gives similar anatomical information as CT (Fig.61), but is better at
multiplanar imaging (coronal and sagittal – Fig.62). It does not use X-rays and therefore
does not expose the patient to radiation and is therefore relatively safe. As large magnetic
fields are use it is very important that electrical and metal objects do not enter the MRI
room. A lot of surgical appliances (prostheses, surgical clips, stents etc.) are now MRI
compatible, but it is very important to verify this first. Electrical objects such as cardiac
pacemakers should never enter the magnetic field.

MRI is invaluable in the characterization of liver, pancreatic and adrenal masses. It also
plays a major role in the staging of rectal tumors and the delineation of anorectal fistulas.
The biliary system is excellently imaged with MRCP (magnetic resonance cholangio-
pancreatography – Fig.63) and MRI is also commonly used in the investigation of the
female genito-urinary system (Fig.62).

Figure 61 Axial T1 weighted MRI of the abdomen at the level of

the pancreas (white arrows). NB On T1 weighted MRI fat appears
bright (high signal) and fluid appears black (low signal).

AO Aorta IF Intraperitoneal fat

L Liver SF Subcutaneous fat
LK Left Kidney SMA Superior mesenteric artery
RK Right Kidney SMV Superior mesenteric vein
 Figure 62 Sagittal T2
weighted MRI of the pelvis.
NB On T2 weighted MRI
fluid appears bright (high
signal).

U Uterus
C Cervix
E Endometrium
M Myometrium
B Bladder
CX Coccyx
D L5 intervertebral disc
P Pubic bone
R Rectum
S First sacral vertebra

Figure 63 MRCP is
a heavily T2
weighted MRI
sequence that
demonstrates the
fluid-containing bile
ducts as high-signal
(bright) structures
and biliary calculi as
low-signal (dark)
foci within the
ductal system.
Stones as small as
2mm can be
detected. Multiple
calculi in both the
extrahepatic bile
duct and gallbladder
(white arrows).
Bright (fluid
containing) liver
cysts are also noted
(red arrows).
ENDOSCOPIC RETROGRADE CHOLANGIO-
PANCREATOGRAPHY (ERCP)

An ERCP is an investigation generally performed by a gastroenterologist, but utilizes

fluoroscopy (continuous x-ray imaging) to help guide the procedure and visualize the
biliary system. The patient is fasted for 6 hours, receives sedation and antibiotic cover
and then lies in the left lateral position. A side viewing endoscope is used. The endoscope
is advanced as far as the ampulla of Vater in the second part of the duodenum. The
ampulla is cannulated and 1-2 mls of radiographic contrast is injected to visualize the
biliary tract. It gives similar diagnostic information as an MRCP, but has the added
advantage of being potentially therapeutic. Biopsies, stone retrieval, biliary stenting and
sphincterotomies can all be performed. Complications of the procedure include acute
pancreatitis, bacteraemia, septicaemia, aspiration and local damage due to the passage of
the endoscope.

Figure 64 A single
image from an
ERCP showing the
endoscope in the
duadenum, contrast
material in the
biliary system
(arrowheads) and a
gallstone in the
common bile duct
(arrow).
Figure 65 Another ERCP image
showing multiple gallstones in a
dilated common bile duct.

Figure 66 View of the biliary

tree post ERCP. Contrast is
seen in the ducts and a biliary
stent (arrows) has been left in-
situ to drain the biliary system.
The lower end of the stent is in
the duodenum.
POSITRON EMISSION TOMOGRAPHY (PET)

PET imaging has increasingly been used in the evaluation and staging of metastatic
disease. It is of particular value in those being considered for surgery and in the
assessment of response to chemotherapy. It is also invaluable in the search for disease
recurrence and helps differentiate between benign and malignant lumphadenopathy.
Currently, glucose is labelled with positron emitting fluorine and is injected
intravenously. This isotope, fluorodeoxyglucose (FDG), is taken up with particular
avidity by tissues with rapid cell turnover and increased cellular metabolism such as
malignant tumours. FDG-PET scanning can be performed along with CT to combine the
functional information of PET imaging with the anatomical information obtained with
CT imaging.

Figure 67 Sagittal fused PET/CT

image of the pelvis in a patient with
recurrent rectal carcinoma (arrow).
PET/CT combines the anatomical
information of CT imaging with the
functional information of FDG PET
imaging. The hot spot seen on PET
imaging is fused with the CT image
to give the exact location of the
recurrent tumor. This is imortant
information for future surgical
excision.
ACKNOWLEDGEMENTS
Images courtesy of M.J.Lee, C.Shortt, A.McErlean and K.Abdulla, Department of
Radiology, Beaumont Hospital.

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