Pattern Of GIT System Pathologies

Abnormal radiological findings of GIT system

CONGENITAL AND HEREDITARYANOMALIES

Esophageal Atresia

Esophageal atresia is a rare congenital anomaly in which the esophagus fails to develop at some past some point, resulting in discontinuation of the esophagus.

The absence in the continuity of the esophagus is due to an inappropriate division of the primitive foregut into the trachea and esophagus. This is the most common congenital anomaly of the esophagus.

Associations

Esophageal atresias are frequently associated with various other anomalies (50-75% of cases).They include:

• Other intestinal atresias
• Duodenal atresia
• Jejunoileal atresia
• Anal atresia
• Annular pancreas

Pyloric stenosis

Subtypes

It is frequently associated with a tracheo-esophageal fistula(TEF). As such, the types of esophageal atresia / tracheo-esophageal fistula can be divided into:

• Proximal atresia with distal fistula: 85%
• Isolated esophageal atresia: 8-9%
• Isolated fistula (h-type): 4-6%
• Double fistula with intervening atresia: 1-2%

Proximal fistula with distal atresia: 1%

Pattern Of GIT System Pathologies

The symptoms of esophageal atresia are visible soon after birth and include excessive salivation, choking, gagging, dyspnea, and cyanosis.

Diagnosis of this congenital anomaly may be established by inability to inability to swallow saliva or milk, aspiration during early feedings, or failure to pass a nasogastric tube(NG tube) into the stomach successfully.

Pattern Of GIT System Pathologies

If a radiopaque NG tube is used, the terminal end of the pouch may be demonstrated radiographically with a chest radiograph without the use of a contrast agent.

Radiographic findings on Plain radiograph

• Chest/abdominal radiograph may show:

Dilated Proximal Esophageal Pouch:

A radiolucent, blind-ended pouch in the upper esophagus is a hallmark finding (A dilated pharyngeal pouch) Gasless Abdomen (without TEF):

If there is no fistula, the abdomen will likely be gasless as air cannot pass through the atresia and absence of gastric bubble.

Bowel Gas (with TEF):

The presence of air in the stomach and/or bowel loops suggests the presence of a distal fistula (TEF) NG Tube Placement:

If an esophagogastric (feeding) tube insertion has been attempted this may show the tube blind looping and turning back at the upper thoracic part of the esophagus or heading into the trachea and/or bronchial tree

Fluoroscopy

Contrast swallow may show contrast blindly ending and pooling in an esophageal stump and/or may show evidence of the tracheo-esophageal fistula.

Fluoroscopy is particularly useful in demonstrating H-type fistula.

PresentationNot tolerating feeds

• Patient DataAge: NeonateGender: Male
• Naso / orogastric tube is curled in the upper mediastinum.

The abdomen is completely gas-less and no gastic air bubble is visible

Patient data:Newborn

Case Discussion

A newborn with esophageal atresia associated with trachea-oesophagal fistula.

Gas in the stomach and small bowel mean that there must be an associated tracheo-esophageal fistula.

Pattern Of GIT System Pathologies

Presentation : Inability to swallow milk, aspiration during feedings. Failure to pass orogastric tube to stomach.Patient Data : Age: 2 days & Gender: Male Plain film shows orogastric tube not passing to the stomach, instead it is turning back superiorly.

After injection of non-ionic water soluble contrast material in the orogastric tube, there is no evidence of passage of contrast to the middle and distal esophagus. The proximal esophagus is dilatation.

Aspiration of contrast is noted from the level of epiglottis rather than proximal tracheo-esophageal fistula.

No distal gas is noted in the stomach, excluding the possibility of distal fistula.

Case Discussion

Isolated esophageal atresia(type A) occurs in approximately 8% of cases of esophageal atresia. In this entity there is no proximal or distal fistula with the trachea.

The possibility of distal distal tracheo-esophageal fistula can be excluded when there is no distal gas in the gastrointestinal tract

Congenital tracheo-esophageal fistula

Is a congenital pathological communication between the trachea and esophagus.

The trachea is an out-budding from the ventral foregut, and tracheo-esophageal fistulae represent incomplete/abnormal division

As such, the types of esophageal atresia / tracheo-esophageal fistula can be divided into:

• Type A: isolated esophageal atresia (8%)
• Type B: esophageal atresia with proximal fistula (1%)
• Type C: esophageal atresia with distal fistula (85% – most common)
• Type D: esophageal atresia with double fistula (1%)

Type E: isolated fistula (h-type) (4%)

Radiographic features on Plain radiograph

Demonstration of the nasogastric tube curled in the proximal esophagus in a child where the passage of the tube has been unsuccessful is usually sufficient for diagnosis. The proximal esophageal stump may be distended with air.

The presence of air in the stomach and bowel in the setting of esophageal atresia implies that there is a distal fistula.

Often the lungs demonstrate areas of consolidation/atelectasis due to recurrent aspiration.

Fluoroscopy

H-type fistulas can be difficult to diagnose and may require contrast swallow studies, looking for contrast passing into the tracheobronchial tree.

This should be performed in lateral position via a feeding tube placed within the esophagus, with contrast carefully injected to distend the esophagus and try to delineate a fistula (tube esophagogram).

Water soluble iodinated contrast (non-ionic) is usually the contrast medium of choice.

Direct Communication:

Fluoroscopy, which provides real-time imaging, is crucial for visualizing the exact site and extent of the fistula.

Contrast material introduced into the esophagus can be seen flowing into the trachea, demonstrating the connection.

Discuss on

Hypertrophic Pyloric Stenosis

Duodenal Atresia

Congenital Gastric Outlet Obstruction

Annular Pancreas:

HYPERTROPHIC PYLORIC STENOSIS

Hypertrophic pyloric stenosis (HPS) is a congenital anomaly of the stomach in which the pyloric canal leading out of the stomach is greatly narrowed because of hypertrophy and hyperplasia of the pyloric sphincter. OR Refers to the idiopathic thickening of gastric py­loric musculature which then results in progressive gastric outlet obstruction.

Its exact cause is unknown, but it seems to be genetically related.

Clinical presentation

While symptoms may start as early as 3 weeks, it typically clinically manifests between 6 to 12 weeks of age in infants.

Clinical presentation is typical with non-bilious projectile vomiting(projectile bile-free emesis) The hypertro­phied pylorus can be palpated as an olive-sized mass in the right upper quadrant.

Affected infants often become dehydrated and fail to gain weight.

It is most commonly confused with pylorospasm, which, in contrast, is an incomplete obstruction to fluid flow into the duodenal bulb resulting from spasmodic changes in pyloric muscle tone.

Radiographic findings of HPS

Plain radiograph

Abdominal x-ray findings are non-specific but may show a distended stomach/gastric distention (single or large bubble)with minimal or no distal intestinal bowel gas.

This is often accompanied by increased gastric peristaltic waves, which may be visualized as the "caterpillar sign“

On occasion, a mass impression of the thickened pyloric muscle on an air-filled gastric antrum may be noted.

caterpillar sign on plain abdominal x-ray

Fluoroscopy

An upper gastrointestinal series (barium meal) directly enhance visualization of the hypertrophied muscle. On upper gastrointestinal fluoroscopy:

• Delayed gastric emptying

Peristaltic waves (caterpillar sign) Elongated pylorus with a narrow lumen (string sign)(often appearing as a thin stripe of contrast material within the lumen) The elongation may appear duplicated due to puckering of the mucosa (double-track sign or railroad track sign) which are multiple linear tracks of contrast separated by the intervening mucosa.

The pylorus indents the contrast-filled antrum (shoulder sign) and (tit sign) or base of the duodenal bulb (mushroom sign)

The entrance to the pylorus may be beak-shaped (beak sign)

Radiographic signs of the HPS

Presentation: Non-bilious projectile vomitingPatient Data -Age: 4 weeks & Gender: Male

• An elongation, narrowed pyloric canal results in string sign.
• Double track sign in region of pyloric canal.

Indentation of base of bulb "mushroom sign"

String sign and double-track sign or railroad track sign

NOTE: Sonography has become the standard and highly accurate method for diagnosing HPS without the need for radiation exposure.

It allows imaging of the pyloric muscle and channel, and the constant imaging of an elongated, thickwalled pylorus indicative of HPS.

Measurements of pyloric channel length, pyloric diameter, and muscle thickness are often used for diagnosis.

Summarize the radiological sign seen in HPS

DUODENAL ATRESIA

Duodenal atresia is a condition where the duodenum, the first part of the small intestine, is completely or partially blocked.

Duodenal atresia results from a congenital malformation of the duodenum and requires prompt correction in the neonatal period. It is considered to be one of the commonest causes of fetal bowel obstruction.

NOTE: In duodenal atresia, there is complete obstruction of the duodenal lumen, while in duodenal stenosis there is an incomplete obstruction of the duodenum lumen.

Associations

Associated conditions are common and include:

Down syndrome: 30% of duodenal atresia cases may have Down syndrome while 3% of Down syndrome cases may have duodenal atresia Annular pancreas

• Other intestinal atresias
• Jejunal atresia
• Ileal atresia

Anal atresia

Clinical presentation

Patients present in early life with duodenal obstruction and associated symptoms of abdominal distension, vomiting and absent bowel movements.

In complete atresia, duodenum ends blindly with no communication with the distal bowel. the child has bilious vomiting. If the atresia is proximal to the ampulla, the vomiting is non-bilious.

The vomiting usually occurs within the first 24 to 38 hours of neonatal life, typically following the first oral feeding and progressively worsens if not treated.

Radiographic features

On plain radiograph

Abdominal radiographs may classically show a ”double bubble sign” with gas filled distended stomach and duodenum with an absence of distal(bowel) gas. A similar appearance (either filled with fluid or gas) can be seen in other modalities.

A double-bubble sign on an abdominal x-ray is a reliable indicator of duodenal atresia with even higher positive predictive value in patients with Down syndrome.

The presence of distal bowel gas, although more classically associated with duodenal stenosis, can be seen in duodenal atresia via anomalous bile duct anatomy.

PresentationA newborn presented with vomiting. He was born with Down syndrome.Patient Data: Age: 10 hours & Gender: Male

Case Discussion

The double bubble sign is a classic radiographic manifestation of duodenal obstruction, the cause of which could be intrinsic (such as duodenal atresia, duodenal stenosis or duodenal web) or extrinsic (such as annular pancreas or rotational anomalies).

Many infants with duodenal atresia also have Down syndrome. Duodenal atresia is often associated with other birth defects Double bubble sign; enlarged duodenal and gastric gas shadows

Double bubble sign

Barium study

Barium contrast can be administered sometimes via an orogastric or nasogastric tube under fluoroscopy to evaluate the upper gastrointestinal tract.

Only a controlled amount of barium is placed to confirm obstruction and its location. It is then removed by nasogastric tube to prevent reflux and potential aspiration.

Plain abdominal x-rays can also show the double-bubble sign, but the barium study provides more detailed information about the location and extent of the obstruction.

No barium contrast passes beyond the duodenal bulb.

Summary

Double-Bubble Sign:

This is the most prominent sign, indicating a dilated stomach and proximal duodenum filled with barium contrast.

Absence of Distal Bowel Gas/Contrast:

The barium study will show no contrast beyond the dilated duodenum, indicating the atresia is preventing the passage of gas and contrast through the small bowel.

Dilated Stomach and Duodenum:

The stomach and duodenum will appear significantly larger than normal due to the obstruction.

Barium Retention:

The barium contrast will remain in the dilated stomach and duodenum, as it cannot pass through the atresia.

How the Barium Study/fluoroscopy study Helps:

Confirms the Diagnosis:

The characteristic appearance of the double-bubble sign and absence of distal bowel gas in the barium study strongly supports the diagnosis of duodenal atresia.

Identifies the Location of the Atresia:

The barium study can help determine the exact location of the obstruction within the duodenum.

Helps Differentiate from Other Conditions:

The double-bubble sign can be seen in other conditions, such as duodenal stenosis or annular pancreas, so the barium study can help distinguish between these possibilities.

ANNULAR PANCREAS

A rare birth defect where a ring of pancreatic tissue encircles the duodenum, the first part of the small intestine.

This can lead to obstruction of the duodenum, causing symptoms like vomiting, abdominal distention, and feeding difficulties, particularly in newborns.

Pattern Of GIT System Pathologies

Annular pancreas, also known as crocodile jaw pancreas, is a morphological anomaly that results in pancreatic tissue completely or incompletely encircling the duodenum. This condition can cause duodenal obstruction

Associations

• Down syndrome
• pancreas divisum
• pancreatitis
• pancreatic cancer

intraductal papillary mucinous neoplasm (IPMN)

Types

Annular pancreas can be either complete or incomplete:

complete annular pancreas: pancreatic parenchyma or an annular duct is seen to completely surround the 2nd part of duodenum incomplete annular pancreas: annulus does not surround the duodenum completely, giving a 'crocodile jaw' appearance

Radiographic Findings

Duodenal Stenosis:

The most prominent finding is a narrowing or constriction of the second portion of the duodenum, where the ring of pancreatic tissue is causing obstruction.

"Double Bubble" Sign:

This is a radiographic hallmark of duodenal obstruction, characterized by a dilated stomach and duodenal bulb, with limited gas distally.

Pancreatic Tissue Ring:

Barium studies may demonstrate the ring of pancreatic tissue surrounding the duodenum, although this may not always be as clear as in other imaging modalities like CT and ultrasound.

Proximal Dilatation:

Due to the obstruction, the stomach and proximal duodenum (duodenal bulb) will be dilated, appearing enlarged on the radiographic images.

HIRSCHSPRUNG DISEASE (CONGENITALAGANGLIONIC MEGACOLON)

Refers to the absence of neurons (Meissner and Auerbach autonomic plexus) in the bowel wall, typically in the sigmoid colon.

A malformation of the parasympathetic nervous system results in the absence of neurons in the bowel wall preventing the normal relaxation of the colon and subsequent peristalsis.

This anomaly results in gross dilatation of the colon to the point of narrowing and constriction.

Pattern Of GIT System Pathologies

This generally becomes apparent shortly after birth, when the affected infant passes little or no meconium and the abdomen becomes distended.

As the patient ages, the continued effects are severe constipation and recurrent fecal impactions.

It is important to diagnose this disease early because it can progress to toxic megacolon if left untreated.

Radiographic features

• On plain abdominal x-ray
• Dilated Proximal Colon:

The colon above the aganglionic segment appears dilated, sometimes with air-fluid levels, suggesting a distal obstruction.

• Narrowed Distal Gut (Aganglionic Segment):

The segment of the colon with the absence of ganglion cells (the aganglionic segment) will appear narrow compared to the proximal dilated colon.

• Transition Zone:

A distinct transition between the dilated proximal colon and the narrowed aganglionic segment is a hallmark finding, often described as a "cutoff sign" or "cone-like" narrowing.

4. Empty Rectum:

The rectum, being part of the aganglionic segment, is typically empty or contains minimal gas.

• Absence of Gas Distally:

A cutoff sign in the rectosigmoid region, with an absence of gas in the rectum and sigmoid, is a significant finding.

• Rectosigmoid Ratio:

The ratio of the rectum to sigmoid may be reversed, with the rectum appearing smaller in diameter than the sigmoid.

FLOUROSCOPY

Barium enema showing reduced caliber of the rectum, followed by a transition zone to an enlarged-caliber sigmoid. Hirschsprung disease.

A 24-hour-delayed radiograph obtained after a barium enema examination shows retention of barium and stool in the rectum. This is associated with a dilated stool-filled sigmoid

Pattern Of GIT System Pathologies

A rectosigmoid index (rectum diameter divided by sigmoid diameter) less than 1 is a common finding. Additionally, a "sawtooth" appearance due to mucosal spasm and retention of barium and stool in the rectum can be observed

Radiographic findings

Rectosigmoid Transition Zone:

This is a key finding, showing a change in bowel caliber from the narrow rectum to the wider sigmoid colon.

Rectosigmoid Index (RSI):

An RSI of less than 1 (rectum diameter/sigmoid diameter) indicates a reduced caliber rectum compared to the sigmoid.

"Sawtooth" Appearance:

The distal bowel may appear irregularly contracted, creating a "sawtooth" pattern on the barium enema.

Microcolon:

In total colonic Hirschsprung disease, the entire colon may appear very small in diameter (microcolon).

• Barium and Stool Retention:

The barium and stool may be retained in the rectum, especially on delayed radiographs.

BOWEL ATRESIA

Ileal atresia, a congenital discontinuation of the ileum, is the most frequent type of bowel atresia, followed by duodenal atresia.

This anomaly manifests a few days after birth.

The most common signs and symptoms of ileal atresia are abdominal distention and the inability of the infant to pass stool. Eventually the infant regurgitates feedings.

Radiographic features

• In plain abdominal x-ray

Dilated bowel loops:

The small bowel loops proximal to the atresia are significantly dilated, often filled with fluid and air.

Air-fluid levels:

Air-fluid levels are present within the dilated bowel loops, indicating a partial or complete obstruction.

• Distended bowel loops:

The dilated loops may appear more prominent and larger in diameter than normal.

Paucity of air distally:

The colon and rectum may have little or no air, indicating that the obstruction prevents the passage of air and stool.

No air in the colon/rectum:

This is a significant indicator of obstruction, as air normally moves through the digestive tract.

Radiographic features in barium studies

Microcolon:

The barium enema will show a small-diameter colon, which is a hallmark sign of ileal atresia. This is because the colon is not receiving normal amounts of meconium or bowel contents due to the obstruction at the ileum.

Dilated Bowel Loops:

The proximal small bowel, above the atresia, will be significantly dilated due to the obstruction, resulting in visible air-fluid levels on x-rays or other imaging.

Absence of Distal Gas:

Normally, air travels through the small intestine and into the colon. In ileal atresia, the blockage prevents this, resulting in the absence of air or contrast in the colon.

No Filling Defects:

Distinguishing ileal atresia from other conditions like meconium ileus is important. In meconium ileus, there might be filling defects in the microcolon due to impacted meconium. In ileal atresia, the microcolon will be a uniform small-diameter without such defects.

DIVERTICULUM

A diverticulum is an out pouching that occurs due to a weakening in the lining of, in this particular instance, the digestive system.

Zenker’s diverticulum arise from the posterior wall of the upper esophagus in the area of the pharynx.

Traction diverticulum is the type of diverticulum forms in the mid esophagus area.

image

Epiphrenic diverticulum arises in the distal esophagus just superior to the lower esophageal sphincter (LES).

They may form as a complication to achalasia.

MECKEL DIVERTICULUM

Meckel's diverticulum is a common congenital anomaly of the gastrointestinal tract, essentially a pouch or outpouching in the small intestine.

Meckel diverticulum is a congenital diverticulum of the distal ileum.

It's a true diverticulum, meaning it contains all the layers of the bowel wall, and it's often a remnant of the vitelline duct (also known as the omphalomesenteric duct), a connection between the fetal intestine and the yolk sac that should close off during development.

It is considered the most common structural congenital anomaly of the gastrointestinal tract.

Pattern Of GIT System Pathologies

Children with Meckel diverticulum often develop an ulcer in the adjacent bowel, and a common sign is repeated episodes of bleeding from the ulcerated site.

Symptoms in adolescents and adults include cramping, vomiting, and bowel obstruction. The symptoms mimic those of appendicitis except for the location of the pain.

Location:

Meckel's diverticulum is typically located on the antimesenteric side of the ileum, near the ileocecal valve (usually within 2 feet of the ileocecal valve

Diagnosis of Meckel diverticulum is difficult, as it may not be visible on a radiograph of the small bowel.

However, nuclear medicine Meckel scans are useful in diagnosing this anomaly by identifying ectopic gastric mucosa.

This is accomplished through injection of Tc-99m pertechnetate, which is taken up by the mucus-secreting cells of the gastric mucosa.

Radiographic features

In plain radiography

While X-rays are not the primary diagnostic tool for detecting Meckel's diverticulum, they can sometimes reveal findings associated with complications like obstruction or perforation.

X-rays can reveal findings suggestive of Meckel's diverticulum complications

Enteroliths:

These are calcified stones that can form within the diverticulum and may be seen as radiopaque structures on an X-ray.

Signs of Intestinal Obstruction:

Dilation of bowel loops, particularly in the small intestine, may be seen on an X-ray, suggesting that the diverticulum is causing obstruction or contributing to it.

Air-Fluid Levels:

If gas or fluid is present within the diverticulum, it might appear as an air-fluid level on an X-ray.

Pneumoperitoneum:

If the diverticulum perforates, a pneumoperitoneum (free air in the peritoneal cavity) may be seen on an upright chest X-ray or a plain abdominal X-ray.

Barium studies (enteroclysis):

Offer better visualization of the diverticulum, and can be helpful in ruling out other causes of bowel symptoms.

• Findings

Blind-ending pouch:

The most characteristic feature is a blind-ending sac or outpouching arising from the ileum.

Triradiate fold pattern:

A mucosal triangular or triradiate fold pattern may be seen at the junction of the diverticulum and the ileum, particularly on barium studies.

Intestinal malrotation

Intestinal malrotation is a birth defect where the intestines don't rotate and fix properly in the abdomen during fetal development. This can lead to complications like twisting of the bowel (volvulus), which can obstruct the blood supply and potentially cause death.

The mesenteric attachment is shortened predisposing to midgut volvulus, and Ladd bands predispose to internal hernia, both potentially fatal.

Terminology

In incomplete rotation, the midgut does not rotate more than 180°, thus the cephalad (prearterial proximal) portion of the midgut is fixed to the right of the superior mesenteric artery (SMA) while the caudad (postarterial distal) midgut is fixed directly anterior to the SMA.

In intestinal nonrotation, the midgut does not rotate more than 90°, thus the cephalad midgut is fixed to the right of SMA and the caudad midgut is fixed to the left of SMA. The cephalad midgut will give rise to the small intestine while the caudad midgut will give rise to the cecum and large intestine.

Associations

It is frequently (~50%) associated with other abdominal anomalies, some of which are causative and others merely associated :

• gastrointestinal tract malformations
• duodenal atresia, stenosis or web
• gastroschisis and omphalocele: always associated with a degree of malrotation
• biliary system malformations
• agenesis of the gallbladder
• intra- and extra-hepatic biliary atresia
• pancreatic malformation
• hypoplasia or agenesis of the dorsal pancreas
• congenital diaphragmatic herniation
• heterotaxy: 70% of individuals will have a malrotation

choanal atresia

Diagnosis

Imaging demonstrates the abnormal positioning of the bowel, related abnormalities and complications.

• Clinical presentation

The clinical presentation of malrotation often correlates with the age of onset.

In the infant, the most common presentation is with midgut volvulus. Patients with intestinal nonrotation have a lower incidence of midgut volvulus than other types of malrotation.

Pattern Of GIT System Pathologies

In the older child or even adult presentation is more frequently intermittent with episodes of spontaneously resolving duodenal obstruction.

This is thought to be due to kinking of the duodenum by Ladd bands rather than a volvulus . Internal hernias are also encountered.

In some individuals, the presentation is very non-specific, with recurrent episodes of abdominal pain and vomiting, diarrhea and weight loss, melena, or chronic pancreatitis

Radiographic features

In Plain radiograph

In the absence of midgut volvulus, abdominal radiographs are neither specific nor sensitive . They may show:

• Right-sided jejunal markings

Absence of stool-filled colon in the right lower quadrant

Fluoroscopy

A pediatric upper gastrointestinal contrast study is the examination of choice when the diagnosis is suspected. The key findings of malrotation is an abnormal duodenojejunal (DJ) junction location:

frontal view

DJ junction fails to cross the midline to the left of the left-sided vertebral body pedicle DJ junction lies inferior to the duodenal bulb lateral view

D2 and D3 segments of the duodenum not located posteriorly in a retroperitoneal position

Although not a specific criterion of malrotation, the jejunum will be commonly located to the right of the spine.

Contrast enema has historically also been used, the theory being that in malrotation the large bowel will also be malrotated.

Unfortunately, in ~25% (range 20-30%) of cases with malrotation, the cecum is normally located. The converse is also true, with the position of the cecum in normal individuals being variable . Very rarely, the cecum may be malrotated and the small bowel in a normal position.

Midgut volvulus

Midgut volvulus is a complication of bowel malrotation usually seen in neonates and infants.

Presentation is usually with proximal small bowel obstruction and bilious vomiting. Without prompt treatment, there is a real and significant risk of small bowel ischemia, significant associated morbidity and even death.

Clinical presentation

Typically, the neonate is entirely normal for a period and then suddenly presents with bilious vomiting.

Unless the volvulus is reduced (or reduces spontaneously), the superior mesenteric vein wrapped around the superior mesenteric artery causes progressive venous obstruction, gradual onset of ischemia, and eventual necrosis.

As this occurs, the abdomen becomes swollen and tender as fluid accumulates in the lumen of the bowel. Eventually, in severe, untreated cases, peritonitis and shock can result in severe morbidity and, sometimes, mortality.

Radiographic features

Plain radiograph

Plain radiograph findings are nonspecific. They may be normal early on, or show developing bowel obstruction as time progresses. Later, in untreated patients, they may show pneumoperitoneum where obstructed, ischemic bowel perforates.

Occasionally complete obstruction can lead to distension of the duodenal bulb and stomach leading to a double bubble sign .

Fluoroscopy

A pediatric upper gastrointestinal contrast study is the examination of choice when the diagnosis is suspected. Not only is it able to identify the volvulus, but even in instances where spontaneous reduction has occurred, the underlying malrotation will be evident.

In the setting of volvulus findings include:

corkscrew sign: a twisted, spiral appearance of the bowel, particularly the duodenum and proximal jejunum.

Tapering or beaking of the bowel in complete obstruction.

Malrotated bowel configuration

Contrast enemas have also been used historically. The theory being that in malrotation the large bowel will also be malrotated. Unfortunately, in 20-30% of cases, the cecum is normally located. The converse is also true, with the position of the cecum in normal individuals being variable.

INJURIES OF THE GIT SYSTEM

Bowel Perforation

A bowel perforation, also known as a gastrointestinal perforation, is a serious condition where a hole develops in the wall of the small intestine or colon.

Plain X-ray Findings:

Free intraperitoneal air : Presence of extraluminal air (black or lucent areas) , particularly under the diaphragm on an upright/erect chest or abdominal X-ray, A condition called Pneumoperitoneum (Air accumulation in the peritoneal cavity, visible as a crescent of gas beneath the diaphragm).

Barium Study Findings:

• Contrast Extravasation: Leakage of barium outside the bowel lumen indicates perforation.

Irregular Bowel Outline: Disruption of the normal bowel contour due to perforation.

Mesenteric Injury

Mesenteric injuries are damages to the mesentery, the tissue that supports the intestines and blood vessels.

These injuries can occur due to blunt or penetrating trauma, and can lead to serious complications like bowel ischemia, perforation, and bleeding.

Plain X-ray Findings:

The erect chest x-ray may show free subdiaphragmatic gas due to traumatic bowel injury but radiographs indicated in the setting of trauma are almost always performed as a supine projection which reduces the sensitivity of pneumoperitoneum.

Abdominal radiography is not indicated in trauma when CT is readily available

Bowel Wall Hematoma

Bowel wall hematomas, a collection of blood within the bowel wall, can be visible on plain abdominal X-rays and barium studies

Radiographic findings in plain radiograph

Intestinal Obstruction:

• The most common finding is evidence of bowel obstruction, which can include:
• Focal Intestinal Distention: Swollen or enlarged sections of the bowel.
• Thickened Wall: The intestinal wall appears thicker than normal due to the hematoma.
• Narrowed Lumen: The passage through the bowel becomes constricted.
• Fixity of Findings: The affected area remains fixed, not moving with peristalsis.

"Stack of Coins" Sign:

This characteristic appearance, where the bowel wall looks like a stack of coins, can be a sign of a small-bowel hematoma.

Barium Studies:

Barium studies can show the presence and level of colonic obstruction due to the hematoma.

Demonstration of Obstruction:

Barium studies, such as barium enema for colon or barium small bowel follow-through for the small bowel, can directly visualize the obstruction.

• Level of Obstruction:
• Barium studies can pinpoint the exact location of the blockage caused by the hematoma.

"Coiled Spring" or "Picket Fence" Signs:

These are additional radiologic signs that can be identified in barium studies, indicating the presence of an intramural hematoma.

Bowel Ischemia

Bowel ischemia, also known as intestinal ischemia, occurs when the small or large intestine receives an inadequate blood supply, leading to potential tissue damage

Plain X-ray Findings:

Plain X-rays in ischemic bowel disease often show nonspecific findings like dilated bowel loops, possible "thumbprinting" (mucosal edema), and in later stages, pneumatosis intestinalis or portal venous gas.

However, normal findings on X-rays don't rule out ischemia, and more specific diagnosis often requires additional imaging like CT scans.

Barium Study Findings

Thumbprinting:

Multiple round, smooth soft-tissue densities projecting into the intestinal lumen, caused by mucosal edema and hemorrhage.

• Thickened and Blunted Folds:
• The normal mucosal folds may become thickened and lose their sharp, regular appearance.

Delayed Transit: Slower progression of barium through the bowel due to motility issues.

ACQUIRED DISEASES OF THE GIT SYSTEM

Peritoneum

PNEUMOPERITONUM

The term pneumoperitoneum refers to the presence of air within the peritoneal cavity.

The stomach is distinguished from free air by the fact that it usually has a fluid level. It should not be mistaken for a pneumoperitoneum, which does not usually show a fluid level unless there is secondary infection (abscess).

Pathology

The most common cause of pneumoperitoneum is the disruption of the wall of a hollow viscus.

The causes and, hence, the corresponding severity of accompanying illness, are variable:

• perforated hollow viscus
• peptic ulcer disease
• ischemic bowel
• bowel obstruction
• necrotizing enterocolitis
• appendicitis
• diverticulitis
• malignancy
• inflammatory bowel disease
• mechanical perforation
• trauma
• colonoscopy
• foreign bodies

iatrogenic

postoperative free intraperitoneal gas

• peritoneal dialysis
• vaginal "aspiration"
• cunnilingus
• douching
• sudden squatting
• postpartum exercises
• water-skiing
• mechanical ventilation
• pneumomediastinum

pneumothorax

Radiographic features in plain radiograph

Chest radiograph

An erect chest x-ray is probably the most sensitive plain radiograph for the detection of free intraperitoneal gas.

If a large volume pneumoperitoneum is present, it may be superimposed over a normally aerated lung with normal lung markings.

• Subdiaphragmatic free gas
• Leaping dolphin sign
• Cupola sign (on supine film)

Continuous diaphragm sign

Leaping Dolphin Sign

On a supine abdominal radiograph, the leaping dolphin sign manifests as a series of parallel, arcuate gas collections outlining the muscle slips of the diaphragm.

This sign occurs because the free intraperitoneal gas outlines the diaphragmatic muscle slips, mimicking the appearance of leaping dolphins.

Cupola Sign

Gas accumulating underneath the central tendon of the diaphragm in the midline.

Seen as a lucency overlying the lower thoracic vertebral bodies, with a well-defined superior border and an undefined inferior border. OR The cupola sign is seen as a lucent area of gas accumulation beneath the central tendon of the diaphragm, usually in the midline.

In a supine patient, the non-dependent gas in the abdominal cavity rises to accumulate under the central tendon of the diaphragm.

Continuous diaphragm sign

Abdominal radiograph

Free gas within the peritoneal cavity can be detected on an abdominal radiograph. The signs created by the free intraperitoneal air can be further divided by anatomical compartments in relation to the pneumoperitoneum:

• Bowel-related signs
• ​​Double wall sign (also known as rigler sign or bas-relief sign)

Telltale triangle sign (also known as the triangle sign or telltale triangle)

​​Double wall sign (Rigler sign)

It's characterized by the visualization of both the inner and outer walls of the bowel on a supine abdominal radiograph due to air present both within the bowel and in the peritoneal cavity.

Telltale triangle sign

The "telltale triangle sign" is a radiographic finding indicating pneumoperitoneum (air in the peritoneal cavity).

It's characterized by a triangular pocket of air, typically seen on a supine abdominal X-ray, bordered by three loops of bowel or two loops and the abdominal wall.

Peritoneal ligament-related signs

Football sign sign: characterized by a large, oval radiolucency resembling an American football, seen in cases of massive pneumoperitoneum This sign is more commonly observed in infants and young children Falciform ligament sign: also known as the "Silver's sign", appears as a linear opacity representing the falciform ligament, which is a fold of peritoneum that connects the liver to the abdominal wall.

This sign can be seen when the falciform ligament is outlined by free air.

Lateral umbilical ligament sign (also known as inverted "V" sign): It's observed as a distinct "V" shape formed by the lateral umbilical ligaments when they are outlined by free air as they course inferiorly and laterally from the umbilicus.

Urachus sign: It represents the outline of the median umbilical ligament with free abdominal gas in a supine patient, as seen on a plain abdominal radiograph.

right upper quadrant signs

Cupola sign

Fissure for ligamentum teres sign: it appears as a vertical, slit-like lucency outlining the extrahepatic portion of the ligamentum teres (remnant of the obliterated left umbilical vein).

Hepatic edge sign: appears as a well-defined linear shadow along the liver's inferior edge, directed superomedially.

Lucent liver sign : shows a reduction in liver opacity due to air located anterior to the liver.

Morison's pouch sign (doge cap sign) :It presents as a triangular-shaped (although may also be crescentic or semicircular) gas lucency, usually bound by the 11th rib in the right upper quadrant on abdominal radiographs due to air in Morison's pouch.

Periportal free gas sign

Case Discussion

The patient had pneumoperitoneum secondary to large bowel obstruction (subsequent CT not shown.

Peptic Ulcer disease(PUD)

Peptic ulcer disease (PUD) involves open sores, or ulcers, in the lining of the stomach or the first part of the small intestine (duodenum).

These ulcers can cause symptoms like abdominal pain, nausea, loss of appetite ,bleeding and vomiting.

• Types of peptic ulcers:
• Gastric ulcer: Located in the stomach.

Duodenal ulcer: Located in the duodenum.

Causes of peptic ulcers

Helicobacter pylori (H. pylori) infection: A common cause, especially for duodenal ulcers.

Nonsteroidal anti-inflammatory drugs (NSAIDs): Long-term use of NSAIDs can increase the risk of ulcers.

Zollinger-Ellison syndrome: A rare condition causing the stomach to produce too much acid.

Peptic Ulcer disease

The art of performing full diagnostic barium meal is gradually getting lost due to endoscopy but is of great importance for settings where endoscopy cannot be achieved.

Barium meals are performed with liquid barium and effervescent to distend the stomach with gas and allow a double contrast image.

Gastric ulcers

Gastric ulcers appear as round or oval collections of barium, but can also be linear or rod-shaped.

• Location: They are typically found in the body or antrum of the stomach.

Features: Radiating mucosal folds may be seen around the ulcer crater.

Radiographic features of gastric Ulcer in fluoroscopy study

Barium meals are performed with liquid barium and an effervescent to distend the stomach with gas and allow a 'double-contrast' image.

• Features of ulceration include
• Pocket of barium filling the ulcer crater
• Edematous collar of swollen mucosa

Radiating folds of mucosa away from the ulcer

bull's eye sign

The bull's eye sign is characterized by a central, ulcerated area within a larger mass, with barium accumulating in the ulcer cavity

PresentationEpigastric pain: Unwilling to undergo endoscopy.Patient Data , Age: 70 years Gender: Male

A small 'pit' of barium contained within an ulcer cavity in the body of the stomach: Bull's eye sign

Duodenal ulcers

• Majority occur on the cap and involve the anterior and posterior walls.
• Dependent wall fill with barium and show radiating folds

Round or oval collection of barium but may be linear when healing Spasms and scarring produce a cloverleaf appearance (in some cases, duodenal ulcers can cause a "cloverleaf" appearance of the duodenal cap) Zollinger Ellison syndrome should be considered in cases with multiple duodenal ulcers

“Cloverleaf” appearance

Inflammatory bowel disease(IBDs)

Crohn’s disease

Crohn’s disease is an inflammatory bowel disease characterized by widespread full-thickness discontinuous inflammation of the GIT, with terminal ileum and proximal colon as the most affected sites.

The involved areas tend to be narrowed, irregular and, sometimes, when a length of terminal ileum is involved, there may be the ‘string sign’ of Kantor.

Radiographic features in crohn’s disease include

• Mucosal ulcers
• String sign- tubular narrowing due to spasm or stricture
• Thickened folds due to edema
• Differential diagnosis
• Acute appendicitis
• Ileocecal tuberculosis

malignancy

Ulcerative colitis

Ulcerative colitis is an inflammatory bowel disease that predominantly affects the colon and rectum.

Clinically patients have chronic diarrhea, associated with tenesmus, pain and fever.

In this case, double contrast barium enema allows for exquisite detail of the colonic mucosa. It is however contraindicated if acute severe colitis is present.

Radiographic features of UC include

• Button shaped ulcers

Lead pipe sign-due to loss of haustral markings, luminal narrowing and shortening

Hiatal hernia

Hiatal hernia

Occurs when there’s herniation of abdominal contents through the esophageal hiatus of the diaphragm into thoracic cavity.

It’s mostly asymptomatic and it is an incidental finding however symptoms may include epigastric or chest pain, postprandial fullness, nausea and vomiting.

• Types of hiatal hernia include
• Sliding hiatus hernia (>90%)

Rolling (para-esophageal) hiatus hernia (<10%)

Pattern Of GIT System Pathologies

Sliding hiatal hernias, where the stomach and gastro -esophagus junction slide up into the chest, and paraesophageal hernias, where the stomach bulges beside the esophagus.

Radiographic features

• Plain radiograph
• Retrocardiac opacity with gas-fluid level
• Fluoroscopy
• Numerous coarse thick gastric folds within the suprahiatal pouch.

Tortuous esophagus with an eccentric gastroesophageal junction

Presentation: Dysphagia

Case Discussion

Large sliding hiatus hernia in a patient with dysphagia

Mediastinal enlargement due to a hiatus hernia with gastrointestinal protrusion into the mediastinum

Differential diagnosis

• On a frontal chest radiograph consider:
• retrocardiac lung abscess
• retrocardiac empyema
• epiphrenic esophageal (pulsion) diverticulum
• phrenic ampulla

postoperative change: esophagectomy with gastric pull-up procedure

Achalasia

Achalasia is a rare swallowing disorder affecting the esophagus, where the lower esophageal sphincter (LES) fails to relax properly, and the esophagus loses its ability to contract and push food down.

Esophageal Achalasia

Symptoms:

• Dysphagia: Difficulty swallowing both solids and liquids.
• Regurgitation: Food or liquid returning up from the stomach.
• Chest pain: May be felt during or after swallowing.
• Weight loss: Unintentional and can be significant.

Other symptoms: Cough, heartburn, and potentially airway infections.

Achalasia

Is a failure of organized esophageal peristalsis causing impaired relaxation of the lower esophageal sphincter, and resulting in food stasis and often marked dilatation of the esophagus.

Obstruction of the distal esophagus from other non-functional etiologies, notably malignancy, may have a similar presentation and has been termed "secondary achalasia" or pseudoachalasia

Radiographic features

• Plain radiograph

Chest radiograph findings include:

convex opacity overlapping the right mediastinum. Occasionally may present as a left convex opacity if the thoracic aorta is tortuous.

air-fluid level due to stasis in a thoracic esophagus filled with retained secretions and food small or absent gastric bubble

anterior displacement and bowing of the trachea on the lateral view patchy alveolar opacities, usually bilateral, may be seen. These represent acute pneumonitis or chronic aspiration pneumonia related to dysphagia.

Fluoroscopy

A barium swallow study is used to confirm esophageal esophageal dilatition, in addition to assessing for mucosal abnormalities.

• Findings include:
• Bird beak sign or rat tail sign
• Esophageal dilatation
• Pooling or stasis of Barium in the esophagus

Uncoordinated, non-propulsive, tertiary contractions incomplete lower esophageal sphincter relaxation that is not coordinated with esophageal contraction

Severe dilation of the thoracic esophagus with a bird beak sign

Gastro esophageal Reflux Disease:

This disease is characterized by a backward flow of gastric contents into the esophagus due to an incompetent lower esophageal sphincter (LES).

GERD is commonly associated with a hiatal hernia.

It is acquired by poor eating habits, obesity, pregnancy, NG tubes, alcohol abuse, tobacco, and as a side effect of morphine

Radiographic features

Barium swallow

A barium swallow is the primary radiographic modality used in the assessment of patients with suspected gastro-esophageal reflux disease.

Approximately 20% of normal individuals will demonstrate some reflus, while some patients with proven pathologic gastro-esophageal reflux disease may not demonstrate reflux during routine examination or only do so after provocative maneuvers such as Valsalva, leg raising, and coughing.

Findings associated with gastro-esophageal reflux disease include:

• Gastroesophageal reflux (demonstrated with provocative maneuvers)
• Hiatal hernia (associated with reflux)
• Impaired esophageal motility

Reflux esophagitis

Widening of gastro-esophageal junction with mild reflux of contrast at lower esophagus.

Ileocecal tuberculosis

The ileocecal region is the most common site of intestinal tuberculosis because of abundant lymphoid tissue, physiological stasis and increased rate of absorption.

The lesion can be ulcerative, hyperplastic, or ulcero-hyperplastic with short annular defect and overhanging edges.

In ileocecal tuberculosis the barium meal follow through is the modality of choice

Radiographic findings in ileocecal TB (barium meal follow through)

• Fleischner’s sign- narrowing of the terminal ileum and ileocecal valve
• Shrunken cecum and pulled up away from RIF
• DDX
• Crohn’s disease
• Cecal carcinoma

Small bowel lymphoma

NEOPLASM OF THE GIT SYSTEM

Esophagus Cancer

Esophagus cancer represents 2% of all cancers and there is a high incidence in smokers and alcoholics.

• The prognosis for this cancer is very poor as it has a 5 year survival rate of 25%.
• It presents with a very “ratty” radiographic appearance on a barium swallow.

Treatment includes Chemotherapy, Radiation Therapy.

Colon cancer

Colorectal cancer is the most common cancer of the GIT. Its clinical presentation is insidious however initial manifestation may be acute such as bowel obstruction, intussusception and heavy rectal bleeding.

Double contrast technique is more sensitive in detecting the lesions.

Radiographic features may include

• Filling defects other than residual fecal matter
• Apple core sign
• Differential diagnoses include
• Diverticulosis
• IBD

Large bowel lymphoma

Apple core sign

The apple core sign, also known as the napkin ring sign, is a radiographic appearance often associated with colorectal cancer.

It describes a short segment of the large bowel that shows an irregular, circumferential narrowing with abrupt, "shouldered" margins, resembling an apple core.

This sign is typically seen on barium enemas or CT scans when a tumor constricts the intestinal lumen

Adenocarcinoma

Often presents as a polypoidal mass, an irregular constricting lesion, or an ulcer with irregular margins, causing filling defects and lumenal narrowing.

Gastrointestinal stromal tumors (gists) May appear as well-defined, exophytic masses with potential for ulceration, necrosis, or cystic changes. They can also cause extrinsic compression or submucosal displacement.

Lymphoma

Can manifest as nodular fold thickening, strictures, or large polypoidal masses within the GI tract.

Other Neoplasms

Benign tumors, like polyps, may appear as smoothly marginated, intramural masses, while malignant tumors often show irregular, infiltrative lesions.

METABOLIC DISEASES OF THE GIT

Common Metabolic Diseases and Radiographic Findings:

Peptic Ulcers:

These can be visualized as barium-filled ulcers, often with surrounding inflammation or mucosal changes.

Hiatal Hernia:

An upper GI series can reveal the upward movement of the stomach, either into or alongside the esophagus, indicating a hiatal hernia.

Tumors:

Both benign and malignant tumors can be identified as filling defects or masses within the GI tract.

Strictures:

Narrowing or blockage of the GI tract due to scarring or other conditions can be seen as a constriction of the barium flow.

Diverticulosis/Diverticulitis:

Barium studies can show the presence of pouches (diverticula) in the colon and, in cases of inflammation, may reveal surrounding edema or abscess formation.

Inflammatory Bowel Disease (IBD):

While barium studies are not the primary diagnostic tool for IBD, they can reveal ulcerations, strictures, and other changes in the bowel wall that suggest inflammation.

Colonic diverticulosis

A diverticulum is a saclike protrusion in the colonic wall that develops as a result of herniation of the mucosa and submucosa through point of weakness in the muscular wall of the colon Both single and double contrast barium enemas can demonstrate diverticula as barium filled outpouchings.

Radiographic features

• Contrast pulling within the diverticulum and forming a meniscus
• DDX

Colonic Polyps

Colorectal carcinoma