1. Gastrointestinal Radiology

2. Contrast media
Type of contrast media
Barium sulfate
Water soluble

3. 1. Barium sulfate 2. Water-soluble contrast agent
สารทึบรังสีที่ใช้ตรวจมี 2 ชนิด คือ
1. Barium sulfate
2. Water-soluble contrast agent

4. BARIUM SULFATE

5. WATER SOLUBLE CONTRAST AGENT

6. Questions
1. The case in aspiration is suspected, which contrast medium is preferred?
2.The case in perforation is suspected, which contrast media is preferred?

7. TECHNIQUE
การตรวจหาความผิดปกติของระบบทางเดินอาหารด้วย barium มี 2 วิธี คือ
1. SINGLE CONTRAST STUDY
2. DOUBLE CONTRAST STUDY

9. SINGLE CONTRAST STUDY

10. SINGLE CONTRAST TECHNIQUE

11. DOUBLE CONTRAST STUDY

12. DOUBLE CONTRAST TECHNIQUE

13. PRINCIPLE ความผิดปกติที่พบในภาพถ่ายรังสีของทางเดินอาหาร แบ่งได้เป็น
2 ประเภทดังนี้
1. ความผิดปกติที่เกิดจากพยาธิสภาพนอกทางเดินอาหาร (Extrinsic lesion)
2. ความผิดปกติของระบบทางเดินอาหาร (Intrinsic lesion)
2.1 Protruded lesion ได้แก่ mucosal fold, polyp, tumor และ varices เป็นต้น
2.2 Depressed lesion ได้แก่ ulcer, diverticulum และ perforation เป็นต้น

14. Diagram C A B submucosal or intramural mass extrinsic mass
mucosal mass A
submucosal or intramural mass B
extrinsic mass C

15. Extrinsic lesion ความผิดปกติที่เกิดจากพยาธิสภาพนอกทางเดินอาหาร
MASS

16. ความผิดปกติที่เกิดจากพยาธิสภาพนอกทางเดินอาหาร

17. ความผิดปกติที่เกิดจากพยาธิสภาพของทางเดินอาหาร: Protruded lesionA B
mucosal mass

18. Polyp A B

19. Diagram
submucosal or intramural mass

22. ความผิดปกติที่เกิดจากพยาธิสภาพของทางเดินอาหาร: Depressed lesionA B
Single
contrast
Double
upright C
En-face
Profile

23. CARCINOMA

24. CARCINOMA (2)

25. CARCINOMA (3)

26. CARCINOMA (4)

27. CARCINOMA (5)

28. ESOPHGUS

29. Achalasia

30. ACHALASIA CARDIA

33. THORACIC DIVERTICULUM
- Arises in the middle third of the thoracic esophagus - Traction diverticulum (arrow) that develops in response to the pull of fibrous adhesion after mediastinal lymph node infection or inflammation (star)

34. EPIPHRENIC DIVERTICULUM
Arises in the distal of the esophagus, just above diaphragm
Pulsion diverticulum (arrow) that probably related to incoordination of esophageal peristalsis and relaxation of the lower esophageal sphincter

36. ESOPHAGEAL VARICES : The characteristic radiographic appearance
1. Serpiginous filling defects which appear as round or oval filling defects resembling the beads of a rosary( dilated venous structures) ( arrowhead) Changes size and appearance with variations in intrathoracic pressure and collapse with esophageal peristalsis and distension Varices related to portal hypertension are most commonly demonstrated in the lower third of the esophagus In portal hypertension ; common accompanying gastric varices(arrow).

37. Answer : CANDIDA ESOPHAGITIS
INFECTIOUS ESOPHAGITIS : Increasingly common because of the use of steroid and cytotoxic drugs, disseminated malignancy, and increasing incidence of acquired immunodeficiency syndrome
CANDIDA ESOPHAGITIS:
: Most common infectious disease of the esophagus
: Radiographic findings include
1. Abnormql esophageal motility ( dilated,
atonic esophagus ) is often an early stage
2. Irregular, nodular, plaque-like mucosal
pattern ( arrow), irregular folds(arrowhead)
with marginal serrations ( shaggy
appearance )
3. Multiple ulcerations of various sizes
4. Frequently involve the entire thoracic
esophagus
Esophagogram

39. Answer : CORROSIVE ESOPHAGITIS
Most severe corrosive injuries are caused by alkalis
Barium study is unnecessary during acute phase.
Radiographic findings;
1. Diffuse superficial or deep ulceration
involving long portion of the distal
esophagus
2. Abnormal motility
3. Fibrotic healing results in a long
esophageal stricture ( arrow) that
extends down to the cardioesophageal
junction.
Note : barium was aspirated into left main
bronchus(green arrow)

41. Major radiographic findings:
EARLY STAGE
- Flat plaque-like lesion or small polypoid lesion) on one wall of the esophagus

42. : Major radiographic appearances (2) :B
ADVANCED STAGE
A. Large Polypoid ( often
fungating ) filling defect
(arrow) with overhanging
edge (yellow arrow)
B. Large ulcer niche (yellow
arrow) within a bulging
mass (ulcerated mass)
(arrow)

43. Major radiographic appearances (3)B
Advanced stage
A. Encircling mass with
irregular luminal
narrowing (green arrow)
and shelf like margins
(black arrow)
B. Nodular thickened folds (varicoid type) (black arrow); Extension of the tumor
(green arrow)

44. PSEUDO-ACHALASIA caused by direct spread to the distal esophagus from gastric carcinoma
Radiographic findings :
1. Irregularly, narrowed and nodular( arrowhead), sometimes ulcerated (arrow), lesion at distal esophagus
2. Rapid transition between normal and abnormal part.
3. Dilatation of proximal esophagus.

46. STOMACH

48. WHAT IS YOUR DIAGNOSIS ?

51. Radiographic appearances of benign gastric ulcer (1)
1. Crater : Barium collection within the ulcer crater
Profile view(A): Penetration of the ulcer projecting beyond the normal barium-filled gastric lumen (arrow)
En-face view(B): Round or oval barium collection on dependent part (arrow)

52. Radiographic appearances of benign gastric ulcer (2)
2.1 Hampton’s line:
an approximately 1-2 mm thin straight line (green arrow)traversing the orifice of the ulcer crater (white arrow)
On profile view represent overhanging normal gastric mucosa of undermined ulcer

53. Radiographic appearances of benign gastric ulcer (3)
2.2 Ulcer collar :
: smooth thick lucent band (arrow) interposed between the ulcer crater (star) and gastric lumen (G)
: represent thickened rim of edematousgastric wall

54. Radiographic appearances of benign gastric ulcer
2.3 Ulcer mound: smooth, sharply delineated, gradually sloping extensive tissue mass (arrow) surrounding the ulcer (arrowhead)
: represent severe edematous gastric wall

55. Radiographic appearances of benign gastric ulcer
3. Radiation of smooth thickened folds (arrow) extending directly to the edge of the crater (arrowhead) on profile view(A) and en-face view (B)

57. Radiographic appearances of benign gastric ulcer (6)
4. Incisula defect :smooth, deep, narrow, sharp indentation on greater curvature(green arrow) opposite a crater (white arrow) on lesser curvature: spastic contraction of circular muscle

58. Chronic Duodenal Ulcer at duodenal bulb
: More than 95% occur in the duodenal bulb
: Associated with H. pylori infection in >95% of cases
: Almost always duodenal ulcers are benign
: Radiographic appearances
1. Ulcer crater : barium collection on dependent part and air-filled with ring shadow on nondependent part

59. Radiographic appearances: Duodenal Ulcer (1)ST
2. Thickened folds ( large arrow)
3. Spasm and deformity of the duodenal bulb (small arrow)
: barium collection in the ulcer crater (green arrow)

60. Radiographic appearances: Duodenal Ulcer (2)B
4. Chronic duodenal ulcer : Deformity of the duodenal bulb from fibrotic healing
- Cloverleaf deformity (A) : symmetric narrowing of the midportion of the bulb with dilatation of the inferior and superior recesses at the base of the bulb (arrow)
- Pseudodiverticulum (B) : asymmetric narrowing of the bulb

61. Answer : Duodenal Diverticulum - Incidental finding in 5%of barium examination
stomach
bulb
Most common found along the medial border of the descending duodenum at periampullary region
Smooth rounded shape with narrow neck projecting beyond the bowel lumen (arrow)

62. Least common site of GI diverticula Location :
Gastric Diverticulum
Least common site of GI diverticula
Location :
- 75% at posterior wall of fundus (arrow)
- Other location :prepyloric area
Note : Pseudodiverticulum from chronic duodenal ulcer at duodenal bulb (arrowhead)

64. Radiographic appearances : Gastric cancer
Polypoid mass
- Small polypoid mass in early stage (arrow) may be indistinguishable from benign polyp
- Large polypoid carcinoma appear as lobulated or fungating masses
- Produce filling defect (arrow) on barium study

66. Radiographic appearances : Gastric cancer (1)
Focal constricting lesion: localized infiltrating carcinoma or localized scirrhous carcinoma
Annular filling defect (arrow)

67. Radiographic appearances : Gastric cancer (2)
Focal constricting lesion
: localized infiltrating
carcinoma or localized
scirrhous carcinoma
- circumferential
irregular narrowing of
the lumen with
rigidity (as figure;
involved body and
antrum)
body
antrum
bulb
fundus

68. Radiographic appearances : Gastric cancer (3)
Linitis plastica pattern
- tumor invasion of the
gastric wall
- diffuse irregular
narrowing and rigidity
of the stomach

69. Gastric Carcinoma at antrum : malignant gastric ulcer
5% of gastric ulcers are malignant
Radiographic appearances:
1. Intraluminal ulcer (not project beyond the expected margin of the stomach ) (arrow)
2. Irregular, nodular mass (arrowhead) surrounding the ulcer
3. Irregular or nodular thickened
folds that radiate to the mass
4. Carman meniscus sign : semicircular or meniscoid ulcers (arrow) with its inner margin
convex toward the lumen

70. Radiographic appearances : Gastric cancer (4)
Ulcerated carcinoma tumor mass (arrowhead) has been replaced by ulceration (arrow)

72. Malignant ulcer from gastric leiomyosarcoma
Tumor of smooth muscle of GI tract
Intramural in origin
Radiographic appearances: 1. Intramural or submucosal mass (green arrow) : obtuse angle with the normal bowel wall (white arrow) 2. Variable appearances: intraluminal, exogastric (extrinsic mass) or mixed form 3. Frequently ulceration (black arrow)

75. COLON

77. Radiographic findings : Colonic Diverticulosis
1. Multiple round or oval outpouchings of barium projecting beyond the lumen on profile view (white arrow), barium collection (white arrowhead) or ring-like lesion (black arrowhead) on en-face view

78. Radiographic findings : Colonic Diverticulosis
2. Criss-crossing ridges of thickened circular muscle (sawtooth configuration) (arrow)

80. Polyp: focal, protruded lesion within the bowel including neoplastic and non-neoplastic lesion
Morphologic Classification :
1. Sessile plaque : flat plaque and base wider than height
2. Sessile hemisphere : semilunar shape polyp and base slightly wider than height
3. Pedunculated sphere : small round polyp with stalk

82. Colonic Carcinoma
Annular Carcinoma (green arrow) with shelf-like margin (black arrow)

83. Colonic Carcinoma
Polypoid Carcinoma (arrow)

85. Tuberculous enterocolitis
Ileocecal area (80-90%)
Radiographic findings :
1. Irregular thickened bowel wall (white arrow) resulting in narrowing of the lumen (coned cecum)(C)
2. Thickened ileocecal valve
3. Wide gap of patulous ileocecal valve (green arrow)
4. Thickened wall of terminal ileum (I)
5. Deep ulcer with/without sinus tract or fistula C I