Radiology Interpretation Made Easy: One Hundred Most Common Diseases Studied G Balachandiran
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GI Tract21

 
1. INTESTINAL OBSTRUCTION
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X-RAY INTERPRETATION
An abdominal X-ray in erect posture shows multiple air/fluid levels. The arrow points to the largest air/fluid level. The largest air/fluid is in the stomach. No gas was found in the colon-distal to obstruction.
 
COMMENTS
The number and the size of air/fluid levels depend upon the site and duration of obstruction. If the patient cannot stand, a X-ray in sitting posture or translateral should be attempted. In paralytic ileus air/fluid levels may be seen in stomach, small as well as large intestine.4
 
2. X-RAY ABDOMEN-SUPINE POSTOPERATIVE OBSTRUCTION
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X-RAY INTERPRETATION
This plain X-ray abdomen in supine view grossly shows dilated jejunal and ileal bowel loops, occupying the centre of the abdomen. The vertical arrow points to the dilated jejunum and horizontal arrow to the thickened volvulae.
 
COMMENTS
The presence of volvulae conniventes points to the dilated jejunal loops. The caliber of the distended lumen, thickness of the volvulae and the distance between loops give valuable information regarding the underlying pathology.6
 
3. PERFORATION
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X-RAY INTERPRETATION
The chest X-ray PA view (always taken in erect posture) shows faint outline of gas (arrows) (black shadows below the white diaphragm) under both domes of diaphragm, an ominous sign of perforation in GIT.
 
COMMENTS
It is better to take a chest X-ray in erect posture to demonstrate air under the diaphragm. AUS examination cannot show the air under diaphragm clearly. US exam would clearly show even small amount of fluid collection either in the Morison's pouch or in pelvic peritoneum. An abdominal X-ray taken in erect will show not only the pneumoperitoneum but also multiple bowel air/fluids indicating paralytic ileus. Rarely the colon interposed below the right dome (Chilaiditi's syndrome) may be mistaken for pneumoperitoneum.8
 
4. SIGMOID VOLVULUS
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X-RAY INTERPRETATION
The plain X-ray abdomen shows the classical COFFEE BEAN sign (the arrow in the line diagram) in cases of sigmoid volvulus. The clockwise twisting of the redundant sigmoid colon along its mesentry results in this characteristic appearance.
 
COMMENTS
The diagnosis of sigmoid volvulus can be made confidently with this X-ray alone. A barium enema (rarely required to diagnose) may show abrupt tapered ending of the barium column, so called bird of prey beak sign. A flatus tube insertion may temporarily untwist the colon. Very rarely a toxic colon may have to be differentiate.10
 
5. STRICTURE OESOPHAGUS
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BARIUM SWALLOW INTERPRETATION
The picture shows a long segment, smooth narrowing (small arrow in the line diagram) of the middle third of the oesophagus. Note the absence of significant proximal dilatation (large arrow) and shouldering sign highly suggestive of malignancy.
 
COMMENTS
Stricture oesophagus due to corrosive poisoning is one of the most common causes of dysphagia especially in young females. This non-invasive method of diagnosis is easily acceptable to the patient. The stomach should also be examined to rule out any similar lesion.12
 
6. OESOPHAGEAL VARICES
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BARIUM SWALLOW INTERPRETATION
Multiple worm like filling defects of varying sizes seen occupying the entire length of the oesophagus indicating marked varices. The oesophagus is also dilated.
 
COMMENTS
Oesophageal varices are the most common manifestation of portal hypertension. Endoscopic grading of varices do not correlate with grading by barium study. Varices may be less prominent after a bout of haematemesis US examination may also show varices.14
 
7. CARCINOMA OESOPHAGUS
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BARIUM SWALLOW INTERPRETATION
The study shows the characteristic RAT TAIL deformity at the lower third of oesophagus. The large arrow in the line diagram shows the dilated proximal third, the small arrow points to the typical shouldering (a sign of endoluminal growth) and the Dotted line shows the irregular, narrowed lumen, indicating the endoluminal proliferative growth.
 
COMMENTS
This study is highly diagnostic and needs no further study. Even upper GI endoscopy may sometimes find it difficult to negotiate an irregular, narrowed lumen and very often endoscopy is a failure due to stasis and stenosis. During this procedure patient may aspirate barium into the respiratory tract. X-rays taken in frontal and lateral projections may give a detailed information about the extent of the tumour.16
 
8. BARIUM MEAL STUDY GASTRIC ULCER
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X-RAY INTERPRETATION
This barium meal study of the stomach shows a large ulcer protruding extraluminally, in the lesser curvature (small arrow). There is also evidence of ulcer collar and Hamptons line (big arrow).
 
COMMENTS
After the advent of H2 receptor antagonist the spectrum of peptic ulcer finding in barium studies has considerably changed. Nowadays it is rare to find such an ulcer. The presence of Hamptons line (oedema at the ulcer base) is a sure sign of beningnity. Generally ulcers along the greater curvature are malignant.18
 
9. BARIUM MEAL STUDY CARCINOMA STOMACH
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X-RAY INTERPRETATION
This barium study of the stomach shows a persistent, intrinsic irregular filling defect in the lesser curvature due to an ulcerative mass. Note the ulcer crater is within the lumen of the stomach (arrow) depicting the classical Carmens sign, a sign of malignant ulcer.
 
COMMENTS
Before endoscopy was introduced barium study was the only way to diagnose stomach growths. Later double contrast study was introduced. Of the several signs that help to differentiate benign from malignant ulcers this Carmens sign is the most useful.20
 
10. BARIUM ENEMA TUBERCULOSIS
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X-RAY INTERPRETATION
This barium enema X-ray shows irregular outline of the ascending colon, caecum, small contracted (small arrow) caecum, narrowed terminal ileum (big arrow). The appendix is displaced by the thickened caecum.
 
COMMENTS
This is the classical presentation of the ileocaecal tuberculosis. The immediate differential diagnosis is Crohn's disease in which skip lesion and long segment stenosis are common.22
 
11. ULCERATIVE COLITIS
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IMAGE INTERPRETATION
This barium enema X-ray shows a smooth descending and transverse colon devoid of the haustrations (1). This is the classical pipe stem colon. On close examination the mucosa shows a fine granular appearance (2).
 
COMMENTS
Of the two non-specific inflammatory diseases ulcerative colitis is very common. The barium findings like pipe stem colon and pseudopolyposis are specific. In toxic dilatation the colon may be grossly dilated (transverse diameter more than five cm).24
 
12. ACUTE APPENDICITIS
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IMAGE INTERPRETATION
The ultrasound image on the left side shows the inflamed appendix in its long axis (arrow). During dynamic study it showed non-compressibility and no peristalsis. Ultrasonic Murphy's sign and Rovsing's sign were also demonstrated. The ultrasound image on the left shows inflamed appendix in its short axis (between arrows) showing the characteristic double ring.
 
COMMENTS
The ultrasound findings for acute appendicitis are very characteristic and confirmatory. There is no need for any further imaging study. The accuracy by ultrasound is nearly 95%. In some cases an appendicolith may appear as an echogenic focus in the base of the inflamed appendix.26
 
13. HYPERTROPHIC PYLORUS
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IMAGE INTERPRETATION
The ultrasound image shows grossly thickened wall of pylorus (small arrow in the line diagram). The large arrow points to the lumen of the pylorus.
 
COMMENTS
This is the classical appearance of hypertrophied wall of the pylorus. Congenital hypertrophy of pylorus can be diagnosed confidently using US alone. Most of the signs of barium study (like shoulder sign, double track sign, etc.) could be demonstrated by US itself. Similar finding in the adult, pylorus is seen in linitis plastica type pyloric growth.28
 
14. INTUSSUSCEPTION
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IMAGE INTERPRETATION
An ultrasound image obtained from the right flank shows bowel loops engulfing each other.
 
COMMENTS
Such finding in the given clinical setting always suggests intussusception. The classical pseudo-kidney appearance (alternate bright and dark bands) described in books is rarely seen. This is more common in children. In adults a tumour may be a leading cause of this condition.