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“Must Know” GI Radiology for Family medicine residents
Joanna R. Fair, M.D., Ph.D. Vice Chair of Education Department of Radiology Some images courtesy of Radiology Department Faculty and Residents and Petra Lewis, M.D. Associate Professor of Radiology Dartmouth Medical School
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GI Imaging Objectives Know the radiographic findings and imaging evaluation of suspected small bowel obstruction Know radiographic findings for other significant bowel findings (large bowel obstruction, pneumoperitoneum) Identify the appropriate imaging evaluation for focal abdominal pain conditions: RLQ pain, suspect appendicitis LLQ pain, suspect diverticulitis RUQ pain, suspect acute cholecystitis Suspect pancreatitis
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Suspected bowel obstruction
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Plain Films Appropriate utilization Assessment Bowel obstruction
Free air (pneumoperitoneum) Assessment Bowel gas pattern Obstruction- small or large bowel Ileus Abnormal air Pneumoperitoneum
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Abdominal film - Normal
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Abdominal film - Normal
Stomach Liver Right kidney Spleen Descending colon Cecum Small bowel
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Normal abdominal series
Supine: bowel caliber Upright: air-fluid levels
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Based on the following image, what is the MOST likely diagnosis
Ileus Small bowel obstruction Large bowel obstruction Perforated bowel Normal SBO
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Based on the following image, what is the MOST likely diagnosis
Ileus Small bowel obstruction Large bowel obstruction Perforated bowel Normal SBO
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Algorithm for suspected SBO
Paulson EK, Thompson WM, Radiology 2015; 275:332–342
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Small bowel obstruction vs Ileus
Dilated small bowel >3 cm Stomach dilated Not all small bowel dilated Decompressed large bowel Upright or decub film: Differential air fluid levels (different levels in same loop) Gasless abdomen Dilated small bowel > 3 cm Large bowel dilated Can have air-fluid levels
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Small bowel obstruction
Paulson EK, Thompson WM, Radiology 2015; 275:332–342
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Small bowel obstruction
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PACS case 1
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Based on this image the MOST likely diagnosis is:
Ileus Small bowel obstruction Large bowel obstruction Sigmoid volvulus Cecal vovulus Distal large bowel obs, but could easily be ileus
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Based on this image the MOST likely diagnosis is:
Ileus Small bowel obstruction Large bowel obstruction Sigmoid volvulus Cecal vovulus Distal large bowel obs, but could easily be ileus Could be distal large bowel obstruction
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Ileus Difficult to distinguish from SBO Look for colon air
Illeus – can be difficult to distinguish from SBO. Look for colonic air, air fluid levels at same level Difficult to distinguish from SBO Look for colon air colon and small bowel distended
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Ileus
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Distal large bowel obstruction
Difficult to distinguish from ileus Dilated large bowel Dilated small bowel if ileocecal valve incompetence
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The most likely diagnosis based on this image is:
Small bowel obstruction Cecal volvulus Paralytic ileus Sigmoid volvulus Sigmoid volvulus
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The most likely diagnosis based on this image is:
Small bowel obstruction Cecal volvulus Paralytic ileus Sigmoid volvulus Sigmoid volvulus
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Sigmoid Volvulus Coffee bean shaped loop ‘pointing’ to LLQ
At risk individuals Elderly, bed bound, chronic constipation,
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What is your BEST interpretation of this image?
Small bowel obstruction Bowel perforation Large bowel obstruction Paralytic ileus Free intraperitoneal air
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What is your BEST interpretation of this image?
Small bowel obstruction Bowel perforation Large bowel obstruction Paralytic ileus Free intraperitoneal air Free intraperitoneal air
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Pneumoperitoneum Upright PA CXR most sensitive film Abdominal film
Lucent crescent under diaphragm (also check lateral) Abdominal film Must have LL decub to see air against liver Supine (need lots of free air) Rigler (double wall) sign CT most sensitive
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Pneumoperitoneum Left lateral decubitis Massive free air over liver
Rigler (double wall) sign Air on both sides of bowel wall
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Pneumoperitoneum Falciform ligament sign Small free air
Football sign left Small free air right Falciform ligament sign Small free air
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Focal Abdominal Pain
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Focal abdominal pain Sites How to select imaging? RLQ pain LLQ pain
RUQ pain Upper abdomen, concern for pancreatitis How to select imaging? ACR Appropriateness Criteria!
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ACR Appropriateness Criteria
From the American College of Radiology Evidence-based Guides appropriate imaging in wide variety of situations Relative utility Relative radiation exposure Google “ACR Appropriateness”
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RLQ pain – suspect appendicitis
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US residents average annually: ☢☢☢ from background + ☢☢☢ from imaging
Relative Radiation Level - RRL Examples ** Estimated added lifetime risk of fatal cancer: Ultrasound; MRI Zero ☢ Chest or Hand Radiographs Minimal or Negligible (1/1,000,000 – 1/100,000) ☢☢ Pelvis Radiographs; Mammography Very Low (1/100,000 – 1/10,000) ☢☢☢ Abdomen CT; Nuc Med Bone Scan Low (1/10,000 – 1/1000) ☢☢☢☢ Abdomen/pelvis CT with and without contrast; PET/CT Moderate (1/1000) ☢☢☢☢☢ CTA chest/abdomen/pelvis with contrast (1/500) US residents average annually: ☢☢☢ from background + ☢☢☢ from imaging
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CT- Appendicitis Right lower quadrant inflammation, abscess, and/or appendicolith Normal appendix Appendicolith with acute appendicitis
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PACS Case 2
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LLQ pain – suspect diverticulitis
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Diverticulitis Diverticulosis
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PACS Case 3
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RUQ pain – suspect acute cholecystitis
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RUQ Ultrasound- Gallstones
Mobile, echogenic focus with posterior acoustical shadowing liver Gb gallstone Gb- Gallbladder
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PACS Case 4
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Nuclear Medicine HIDA (Cholescintigraphy)
If US is equivocal Small amount of radiotracer, IV Targets a particular organ or physiology, in this case, liver + biliary tree
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Normal HIDA Liver shows up immediately
Blood pool disappears in 5-10 min Rapid progress into biliary tree Goes into CBD, small bowel, GB
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Case
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Case Part 2 No GB @ 4 hours Acute cholecystitis No GB @ 30 min
Option 2: 2 mg MSO4, wait 30 min Option 1: Wait 4 hours No 4 hours Acute cholecystitis No 30 min Acute cholecystitis
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Upper abdominal pain – suspect pancreatitis
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2 echogenic stones in the distal CBD
US of the CBD 2 echogenic stones in the distal CBD
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PACS Case 5
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Summary Start with plain films for suspected bowel obstruction
CT often needed next Use ACR Appropriateness Criteria to select advanced imaging for abdominal pain CT for suspected appy, diverticulitis, complicated pancreatitis US for suspected acute cholecystitis, uncomplicated pancreatitis Nuclear Medicine HIDA for acute cholecystitis if ultrasound equivocal
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