Imaging the Upper GI Tract and Hepatobiliary System

Question 1

What are imaging methods used on the gastrointestinal tract

Answer 1

Alimentary tube: plain film, barium studies, computed tomography, MRI, fibre-optic endoscopy

Question 2

What length should the small bowel be in plain film

Answer 2

3cm

Question 3

What barium radiology do you use to look at the oesophagus

Answer 3

Barium swallow

Question 4

What barium radiology do you use to look at the stomach/ duodenum

Answer 4

Barium meal

Question 5

What barium radiology do you use to look at the small intestine

Answer 5

Barium follow through and small bowel enema

Question 6

What barium radiology do you use to look at the colon

Answer 6

Barium enema

Question 7

What do you need for upper GI tract barium radiology

Answer 7

Fasting and smooth muscle relaxant

Question 8

Why do you use a smooth muscle relaxant in barium radiology and what would you use

Answer 8

Use buscopan. Smooth muscle relaxant eliminates peristalsis and spasm

Question 9

What do you need for lower GI tract barium radiology

Answer 9

Bowel cleaning and muscle relaxant

Question 10

Why do you need an empty bowel for barium radiology

Answer 10

So that you can see the mucosal lining of the bowel (prevents food from sticking)

Question 11

How do you distend the upper bowel

Answer 11

Patient drinks a drink with specific fizzy granules

Question 12

How do you distend the lower bowel

Answer 12

CO2 is put up the back passage

Question 13

Describe the principles of double contrast barium radiology

Answer 13

Barium coats the mucosa, gas (air or CO2) distends the bowel lumen

Question 14

What are the two types of single contrast techniques in barium radiology

Answer 14

Contrast swallow and gastrografin enema

Question 15

Describe contrast swallow

Answer 15

Emergency examination; no prep; look for gross abnormality e.g. leak, perforation, bolus obstruction; no mucosal detail; water soluble contrast used (NOT gastrografin)

Question 16

Describe gastrografin enema

Answer 16

emergency examination; no prep; look for gross abnormality e.g. complete obstruction, perforation, fistula; no mucosal detail; no muscle relaxant of gas used

Question 17

What is normal oesophageal peristalsis

Answer 17

Primary peristalsis followed by secondary peristalsis

Question 18

What does abnormal oesophageal motility show

Answer 18

Tertiary contractions

Question 19

What does a prone motility study require

Answer 19

Primary peristalsis followed by secondary peristalsis

Question 20

What is the function of secondary peristalsis

Answer 20

To clear anything left over from the primary swallow to the stomach

Question 21

Describe a barium meal

Answer 21

Requires ionising radiation, relatively insensitive, does not permit biopsy

Question 22

Describe endoscopy

Answer 22

No ionising radiation, direct inspection of mucosa, allows biopsy, limited mobility required

Question 23

Why is endoscopy preferred

Answer 23

No ionising radiation, allows direct inspection of mucosa, allows biopsy and limited mobility is required

Question 24

Describe upper gastrointestinal CT

Answer 24

Limited diagnostic value; mainly used for staging known oesophageal or gastric cancers, post-operative complications; needs gastric distention so IV buscopan and drink water or omnipaque

Question 25

Describe small bowel follow through studies

Answer 25

Patient drinks barium, barium followed through small bowel

Question 26

Describe small bowel enema

Answer 26

Enteroclysis- tube examination, contrast infused into small bowel, better distention of small bowel

Question 27

What show the small bowel better than plain film

Answer 27

Barium studies

Question 28

What is ultrasound used for

Answer 28

To evaluate terminal ileum and appendix and to look for collections. Limited value in examining rest of bowel. Operator and patient dependent

Question 29

Describe CT or MRI enterography

Answer 29

fairly new techniques. Give larger volumes of oral bulking agent e.g. kleenprep (a laxative which draws fluid into the bowel). Bulking agent distends small bowel and acts as negative/ positive contrast

Question 30

Why use CT or MRI

Answer 30

CT good for initial diagnosis and acute abdomen, MRI better for monitoring disease. CT is very quick but there is quite a lot of radiation. For MRI you lie still for 20-30 minutes for good pictures. MRI shows normal and abnormal thickening of the bowel wall

Question 31

Describe capsule endoscopy

Answer 31

If you want lumenal views of the small bowel then you need to use capsule endoscopy. However capsule endoscopy is hard to interpret. It is used mainly in difficult cases when you are unsure of the pathology

Question 32

What is used in large bowel imaging

Answer 32

Barium enema, CT pneumocolon and colonoscopy

Question 33

What is T1 MRI good for

Answer 33

Anatomy, the fluid is dark

Question 34

What is T2 MRI good for

Answer 34

Pathology, the fluid appears bright

Question 35

Describe MRCP

Answer 35

Sequence imaging which is heavily T2 weighted

Question 36

What does erect barium swallow allow you to see

Answer 36

Demonstration of the anatomy from pharynx to gastro-oesophageal junction (cardia)

Question 37

What does prone barium swallow allow you to see

Answer 37

Allows assessment of oesophageal peristalsis i.e. physiology

Question 38

What are 3 the anterior indentations of the oesophagus caused by

Answer 38

1st indentation- aortic arch. 2nd indentation- left main bronchus. 3rd indentation- left atrium

Question 39

What are the indentations in the oesophagus at risk of being

Answer 39

A stricture

Question 40

What does a barium meal allow good demonstration of

Answer 40

Fundus, body, antrum, pylorus, duodenum

Question 41

Describe small bowel anatomy

Answer 41

Jejunum- left upper quadrant, prominent fold pattern, larger calibre lumen. Ileum- right lower quadrant, more featureless, narrower lumen, terminates at ileo-caecal valve

Question 42

What can be used to image the biliary tract

Answer 42

Ultrasound, magnetic resonance scanning (MRCP), endoscopic retrograde cholangio-pancreatography (ERCP), endoscopic ultrasound (EUS)

Question 43

What do you mainly use to look at the biliary tree

Answer 43

Ultrasounds

Question 44

What is odynophagia

Answer 44

Pain when swallowing due to disorganised contraction and corkscrewing of the oesophagus

Question 45

What is the best way of locally staging cancer

Answer 45

Endoscopic cancer

Question 46

What does PET show

Answer 46

Metastases

Question 47

What is the colon commonly affected by

Answer 47

Chrome's disease or inflammatory conditions

Question 48

What does fat wrapping show

Answer 48

The small bowel is inflamed

Question 49

What does a positive Murphy's sign mean

Answer 49

Tender gall bladder

Question 50

What are inflammatory markers

Answer 50

WBCs CRP (c-reactive protein)

Question 51

What are possible causes of strictures of the biliary tree

Answer 51

Neoplasms- cholangiocarcinoma, gallbladder adenocarcinoma, pancreatic adenocarcinoma, metastasis; Post-inflammatory- pancreatitis, post radiation or chemotherapy; Inflammatory- AIDS cholangiopathy, biliary parasites, primary sclerosing cholangitis. No obstruction: caroli disease, choledochal cyst, recurrent pyogenic cholangitis, primary sclerosing cholangitis

Question 52

What can obstruction of the biliary tree be caused by

Answer 52

Stones or strictures

Question 53

What are symptoms of a Klatskin tumour

Answer 53

Painless jaundice, itching, weight loss