Practical radiology of the small and large intestine Prepared by Dr Sarah Kamal Radiology lecturer اسم ورقم المقرر – Course Name and No. 5/6/2019

By the end of this lecture, the student should be able to: Learning objectives By the end of this lecture, the student should be able to: Describe radiological anatomy of the small and large intestine Mention different imaging modalities used to assess medical conditions of both the small and the large intestine Describe the radiological features of some common pathological conditions affecting this region. اسم ورقم المقرر – Course Name and No. 5/6/2019

2 1 3 4 Plain x-ray abdomen and pelvis AP view

Plain x-ray abdomen and pelvis AP view Transverse colon stomach cecum Descending colon Plain x-ray abdomen and pelvis AP view

Large vs small bowel Large bowel Small bowel Peripheral (except RUQ occupied by liver) Haustral markings don’t extend from wall to wall Small bowel Central Valvulae conniventes extend across lumen and are spaced closer together

Comparison of large and small bowel Valvulae conniventes: extend across lumen and are spaced closer together Many loops Centrally placed 3-5cm اسم ورقم المقرر – Course Name and No. 5/6/2019

•Peripheral distribution •>5cm Large bowel •Haustra: Haustral markings don’t extend from wall to wall •Fewer loops •Peripheral distribution •>5cm اسم ورقم المقرر – Course Name and No. 5/6/2019

Plain x-ray abdomen AP view اسم ورقم المقرر – Course Name and No. 5/6/2019

TECHNIQUE 1. SINGLE CONTRAST STUDY 2. DOUBLE CONTRAST STUDY

•There are two varieties of barium study: single and double contrast meals. •A single contrast study uses only barium, a radioopaque (or positive) contrast medium, to image the upper gastrointestinal tract. •A double contrast study uses barium as well as a radiolucent (or negative) contrast medium such as air, nitrogen, or carbon dioxide. •The double contrast meal is more useful as a diagnostic test, demonstrating mucosal details and allowing the detection of small mucosal lesions such as diverticula or polyps. اسم ورقم المقرر – Course Name and No. 5/6/2019

Barium Studies of the GI Tract Barium enema http://www.nlm.nih.gov/medlineplus/ency/article/003817.htm

4 5 6 3 7 2 8 1

Rectum Sigmoid colon Descending colon Splenic flexure Transverse colon Barium enema double contrast study 4 5 6 Rectum Sigmoid colon Descending colon Splenic flexure Transverse colon Hepatic flexure Ascending colon cecum 3 7 2 8 1

5 2 1 6 4 3 CT Abdomen axial with contrast

5 2 1 6 4 3 1- Rectum 2-Sigmoid colon 3-Descending colon 4-Ascending colon 5-Transverse colon 6-Cecum CT Abdomen axial with contrast

3 2 4 1 5 6 CT Abdomen reformatted with contrast

Double contrast study with features of an outpouching mass from the large intestinal wall into the lumen suggesting Polyp A B

Is this study normal or abnormal? And why? Abnormal barium enema Showing narrowing in the intestinal wall with shouldering suggesting Colon Cancer (apple core sign)

Colonic Carcinoma Annular Carcinoma with shelf-like margin Barium enema Annular Carcinoma with shelf-like margin

Lead pipe colon Shortening of colon secondary to fibrosis Loss of haustration Ulcerative colitis

Ulcerative colitis Feature-less colon(lead pipe appearance)

NORMAL What is the diagnosis?

Barium enema Sigmoid cancer

Small bowel imaging

Small bowel imaging The small intestine is one of the most difficult areas to study radio graphically in the gastro-intestinal tract; yet, satisfactory examinations are needed to give the maximum definition of every inch of the intestine .

Barium Studies of the GI Tract Small bowel follow-through The passage of the barium through the esophagus, stomach, and small intestine is monitored on the fluoroscope. The test usually takes around three to six hours. http://www.nlm.nih.gov/medlineplus/ency/article/003816.htm http://www.vh.org/adult/provider/internalmedicine/GIAtlas/Organ/pages/4-S-Intestine/NormalImage7.html

اسم ورقم المقرر – Course Name and No. 5/6/2019

Mechanical Small bowel obstruction Dilated small bowel Fighting loops (visible loops, lying transversely, with air-fluid levels at different levels) Little gas in colon, especially rectum

Plain x-ray Abdomen AP view with multiple air fluid levels suggesting Small bowel obstruction

Thank you اسم ورقم المقرر – Course Name and No. 5/6/2019