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Radiology 2 > Abdomen 1 > Flashcards

Abdomen 1 Flashcards

1
Q

Imaging studies of the abdomen

A
  • Single KUB and plain abdominal series (plain xrays)
  • Ultrasound
  • Barium studies
  • Nuclear studies
  • GU tract - ultrasound, IVP
  • All things CT next week
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2
Q

abdominal plain films

A
  • Utilized much less - limited
  • Conventional radiographs of the abdomen (plain films) are NOT the first choice to evaluate organs, structures – CT, ultrasound much better
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3
Q

Single, supine film (KUB) indications

A
  • KUB = kidney, ureter, bladder

- Bowel gas pattern, foreign bodies, calcifications, tubes

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4
Q

Abdominal series (KUB, upright abdomen, and CXR) indications

A
  • Suspected bowel obstruction or perforation (pneumoperitoneum): Upright abd: air-fluid levels in bowel, free air, CXR: free air under diaphragms, lung pathology near diaphragm
  • substitute LL decubitus if can’t stand (free air, air fluid levles)
  • special views: prone abdomen, lateral rectum
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5
Q

Adequacy of abdominal plain films

A
  • KUB - diaphragms to symphysis, lateral walls
  • Upright - Pt stands for 5-10min, mid abdomen, beam must be horizontal to floor
  • CXR – must include both diaphragms and costophrenic angles
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6
Q

Normal bowel characteristics: small bowel

A
  • Central distribution
  • Little air in lumen
  • No feces
  • Valvulae conniventes (Traverse entire lumen, Narrow spacing)
  • <2.5cm diameter
  • Wall thickness <3mm
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7
Q

Normal bowel characteristics: large bowel

A
  • Peripheral distribution (Except RUQ, transverse)
  • Contains feces/air
  • Haustra (Do not usually traverse lumen – wide spacing)
  • <5cm diameter
  • Wall thickness <3mm
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8
Q

Patterns: plain films

A
  • Bowel Gas & Air/fluid levels: Normal - Gas in stomach, air-fluid level on upright films, Gas in colon/rectum (No air-fluid levels, variable pattern), small bowel – small amount gas/fluid ok (2 or 3 loops))
  • Calcifications: Not normal - indicate subacute or chronic process, +/- sx’s
  • Organomegaly/Mass: Plain film not study of choice, Displaced bowel may be seen
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9
Q

abnormal gas/fluid patterns

A
  • Abnormal location of gas filled bowel (Shifted/displaced by a mass)
  • Abnormal air-fluid patterns (upright) (Multiple loops of dilated small bowel w/ air-fluid levels, Gastric dilation (stomach) )
  • Abnormal bowel gas patterns (Mechanical Ileus -> SBO - small bowel obstruction, LBO - large bowel obstruction)
  • Functional Ileus (Localized, Generalized (adynamic))
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10
Q

Small bowel obstruction

A
  • Abnormally dilated loops of small bowel
  • Mechanical obstruction – lumen is obstructed from inside or outside (squished)
  • Complete: no air distal to obstruction site (No air in sigmoid or rectum)
  • Partial: some air distal but the bowel is less dilated than obstructed segments of bowel
  • Early obstructions or ileus - difficult to tell
  • Gas in rectum does not “rule out” SBO
  • Location: if proximal, less dilated loops than if distal
  • You know it is small bowel by the valvulae conniventes
  • In SBO – there should always be more dilated small bowel compared to large bowel
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11
Q

What can you see on supine view (KUB) of SBO

A
  • Supine view (KUB) ->
  • Dilated loops small bowel, >3cm
  • See the valvulae conniventes
  • Centrally located, lines up in rows
  • “Stack of coins”, “bent finger sign”
  • Little or no air in rectum
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12
Q

What can you see on upright view of SBO

A

Upright view ->

  • Air-fluid levels: Upside down “U” or broad base
  • “U” ends at different heights, step-ladder appearance
  • “String of pearls” sign - air in valvulae conniventes
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13
Q

Large bowel obstruction

A
  • Large bowel dilated, >5cm (Large, diffuse throughout)
  • Causes: mechanical (mass or twist), fecal impaction, inflammation
  • If ileocecal valve competent - no air in small bowel, cecum most dilated
  • If ileocecal valve incompetent - air in both large and small bowel (Difficult Dx – resembles SBO/generalized ileus)
  • Few/no air-fluid levels, little/no air in rectum
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14
Q

Special types of LBO

A
  • Sigmoid volvulus - “coffee bean” - Huge single loop, usual direction from LLQ to RUQ, 60% of volvulous in adults )
  • Cecal volvulus - Huge, single, kidney-shaped segment, Usual direction from RLQ to LUQ)
  • Toxic megacolon/Ischemic colitis - Huge with bowel wall edema - “thumbprinting”
  • Ogilvie’s Syndrome - Elderly, bedbound, anticholinergics, Lose peristalsis, entire colon dilated
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15
Q

DDx mechanical obstruction

A
  • SBO: Hx SBO strong risk, Post-surgical - adhesions, Malignancy - tumor, Hernia, Intussusception, Inflammatory Bowel Dz
  • LBO: Malignancy - tumor, Hernia, Volvulous, Diverticulitis, Intussusception, Fecal Impaction
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16
Q

Colitis

A

-Large bowel dilated and inflamed but not obstructed
-Loss of haustra
“thumb-printing” of bowel wall from bowel edema, pseudopolyps (TM)

  • Usually very sick patient
  • Toxic Megacolon, Ischemic colitis, Ulcerative colitis, C. Diff colitis, etc.
  • High risk for perforation

-CT best imaging study

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17
Q

types of functional ileus

A
  • Localized

- Generalized (adynamic)

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18
Q

Localized ileus

A
  • Single or few dilated loops - usually SB
  • theres nothing actually blocking the bowel, its just inflamed and pissed off
  • Located near inflammatory process -appy, pancreatitis, tic’s, stones, fx’s
  • “Sentinel loop”
  • Usually air in LB, rectum
  • Less dramatic than SBO
  • Persistent – seen on all views
  • dilated loops near area of inflammation. Persistently dilated on all views, can have air-fluid levels on upright
19
Q

Generalized Ileus

A

-Entire bowel dilated - both large and small loops
-Air-fluid levels common
-Causes: post-surgical, electrolytes, DKA, medications
-Usually air in LB and rectum
-see dilation of BOTH large and small bowel. Hx is key: post surgery common. Bowel sounds often absent if generalized
Ogilvie’s – pseudo-obstruction – bowel sounds often present

20
Q

Calcifications on KUB

A
  • Lamellar (laminar)
  • Amorphous
  • Rimlike
  • Tracklike
21
Q

extraluminal air

A

Pneumoperitoneum – CXR (Lateral most sensitive for small amounts)

  • Retroperitoneal air – plain ok but CT best (Streaky outlining of aorta, psoas, kidneys, bladder - may have pneumomediastinum, Little movement of air w/ position change (xray), Trauma, perforation, infection)
  • Air in bowel wall - Pneumatosis intestinales (Kids: necrotizing enterocolitis; adults: ischemic bowel)
  • Air in the biliary system – pneumobilia (Gas in/around GB or “tubelike” lucencies in RUQ, Erosion or gas forming bacteria)
22
Q

pneumoperitoneum

A
  • Air or gas in the peritoneal cavity 3 xray signs: Free air under the diaphragm(s) on upright PA CXR, Rigler’s sign – see both sides of bowel wall – large amt, KUB, upright, Visualize falciform ligament on KUB)
  • CT – (best test) “double wall sign”, falciform ligament
  • Causes: Perforation of hollow viscous, Iatrogenic: surgery, procedures, trauma (After surgery, last 5-7 days, less daily), Peritonitis with gas forming organisms
23
Q

rigler’s sign

A

can see both sides of bowel wall clearly – air must surround it to see it so clearly (we can normally only see the air inside the bowel and the wall is not so distinct). Need a large amount of free air to see this sign.

24
Q

Barium studies

A
  • Being replaced by Endoscopy (upper) and Colonoscopy (lower)
  • Fluoroscopy utilized for the study
  • Contrast fills spaces, avoids masses
  • Double contrast = air + liquid contrast
  • Bowel prep important (fasting, cathartics)
  • Used to study lesions in: Esophagus, stomach, small bowel, colon
25
Q

Esophagus - contrast studies

A
  • Indications: Dysphagia, perforation, foreign body, strictures, motility problems, malignancy
  • Specific conditions: Zenker’s diverticulum, Barrett’s esophagitis, Hiatal hernia, etc
  • Technique: biphasic esophagogram: Fluoroscopic swallowing studies
  • Endoscopy now more common
  • Zenker’s diverticulum: upper esophageal pouch (diverticulum). Rare, elderly, dysphagia, aspiration.
  • barium is more common for looking at function, edoscopy is more common for looking for THINGS or masses
26
Q

Normal Barium Swallow Indentations

A
  1. aortic arch
  2. left mainstem bronchus
  3. esophagogastric junction
27
Q

“apple core” lesion vs achalasia

A
  • apple core: you have masses on the sides of the esophagus - “Apple core” type lesions also seen in the colon and rectum - high incidence malignancy
  • achalasia: you have a stricture, narrowing, or closure of esophagus
28
Q

Upper GI - SB follow through

A

-Timed oral contrast
Flouroscopy

-Ruggae of Stomach
Entire small bowel, esp terminal illeum

-Crohn’s Dz – see patchy
“skip lesions”, ulcers, “cobblestoning”
Can also dx Inflamatory Bowel Dz, masses, etc

29
Q

Large Bowel - barium enema

A
  • Colonoscopy is now the initial study for rectal bleeding, suspected malignancy
  • CT w/ con not initial test for lesions inside the bowel
  • Double Contrast study common: Barium + Air 
  • Barium enema still used for: Crohn’s dz, Ulcerative Colitis, Diverticular disease, Malignancy, Fistula formation, Intussusception
30
Q

Endoscopy of the esophagus

A
  • Same indications as for barium studies
  • Biopsy possible during procedure
  • Esophagitis
  • Malignancy
  • UGI Bleeds, Mallory Weiss Tear, Esophageal Varices, Boerhaave’s
  • Swallowed FB’s
31
Q

Endoscopy of the stomach

A
  • May include proximal small bowel
  • Biopsy possible during procedure
  • Indications: Gastritis, gastric ulcers, Gastric Tumors, Gastric Outlet Obstruction, Post surgical

-Alternative: Video Capsule Endoscopy

32
Q

Colonoscopy

A
  • Bowel prep is key
  • Same diagnostic indications as barium enema
  • Screening for malignancy >50yo, family hx
  • Rectal bleeding (painless)
  • Stool abnormalities, Hx LBO
  • Colitis: Crohn’s, Ulcerative Colitis
  • Biopsy of suspicious lesions possible
33
Q

Abdominal ultrasound

A
  • Indications:
  • Biliary system - best initial test: Gall Bladder, Gallstones, Common Bile Duct
  • Bladder – urinary retention, post-void residual
  • Kidneys – hydronephrosis, cystic masses, parenchyma
  • Liver & Ascites - free fluid in abdomen, liver parenchyma
  • Aorta – aneurysm
  • Appendix – kids, adults too
  • Trauma - free fluid in abdomen (FAST exam)
  • BEST FIRST TEST FOR GALLBLADDER
34
Q

Biliary system

A
  • Where is the problem?
  • Ultrasound - the first test
  • ERCP: Endoscopic Retrograde Cholangiopancreatography
  • MRCP: MR Cholangiopancreatogram, MRI images of biliary tree; no contrast needed
35
Q

Cholecystitis on ULS: dx criteria

A 
-Gallbladder wall
thickening
-Peri-cholescystic
fluid (black stripe)
-Sonographic
Murphy’s Sign
-Common Bile Duct dilation 
>6mm diameter
-Gallstones commonly seen; “acalculous cholecystitis” possible
36
Q

ERCP

A
  • Endoscopy with Flouroscopy: Dye into Ampulla of Vater, past Spinchter of Oddi
  • Biliary tree stones/obstruction, pancreas
  • Malignancy
  • Cholangitis
37
Q

MRCP

A
  • Same indications
  • No contrast (T2)
  • Non-invasive
  • Can use gad in special situations

-Preferred if MRI available

38
Q

HIDA Scan (biliary scan)

A
  • HIDA scan = hepatobiliary iminodiacetic acid scan
  • Nuclear medicine study
  • Integrity of hepato-biliary tree
  • Indications: Acute cholecystitis, Chronic tract disease, Congenital disease, Post operative bile leak/fistula, Assess liver transplant functioning
39
Q

GU tract - kidneys/bladder

A

-Ultrasound – bladder (retention), kidney (hydronephrosis), formal study for renal parenchymal disease/kidney failure
-CT scan - renal/ureteral stones - no contrast
-IVP - intravenous pyelogram – structural abnormalities
Plain film (KUB) no longer used for renal stones
-Cystoscopy: Bladder cancer, recurrent infections
-Retrograde Urethrogram -> Flouroscopy, Urethral strictures, Trauma – urethra/bladder injury

40
Q

Bladder ultrasound

A
  • Indications:
  • Bladder mass/cancer
  • Urinary retention: Common w/ prostate enlargement, Measure volume of bladder before and after voiding = “post-void residual”, Helps guide foley placement, Urologist tx
  • FAST exam: Looking for free fluid around the bladder
41
Q

Hydronephrosis on ULS

A
  • A ureteral stone (kidney stone passing downstream) obstructs the ureter. Kidney continues to produce urine, urine backs up into the ureter and renal pelvis = hydroureter (best on CT) and hydronephrosis (seen on US).
  • Hydronephrosis is diagnostic for obstructing renal calculi.
42
Q

Intravenous pyelogram (IVP)

A

-Plain KUB series after contrast. Evaluates the patency/efficiency
of the renal collecting system. Usually ordered by Urologists

43
Q

Appendicitis on Ultrasound

A

-Thin pt? High frequency linear probe
Not thin? Low frequency curvilinear probe

  • Classic location: RLQ (or where it hurts): Identify illiac crest, illiac artery, psoas muscle, cecum
  • Can be hard to see it if not inflamed
  • Positive findings:
    • Dilated >6mm
    • Non-compressible
    • Thickened wall
    • Peri-appendiceal fluid
44
Q

free fluid: abdomen

A
  • Ascites (cirrhosis, cancer, etc.): Ultrasound – best choice to identify/confirm ascites, CT w/ oral & IV contrast for cause (liver, etc…)
  • Trauma: Ultrasound - FAST exam immediately, If FAST positive for fluid in trauma – assume blood
  • Clinical scenario dictates both ultrasound and CT interpretation

Radiology 2 (3 decks)

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