RADIOLOGICAL RADIOLOGICAL EXAMINATION OF THE EXAMINATION OF THE

DIGESTIVE CANALDIGESTIVE CANAL

DEPARTMENT OF ONCOLOGY AND DEPARTMENT OF ONCOLOGY AND RADIOLOGYRADIOLOGY

PREPARED BY I.M.LESKIVPREPARED BY I.M.LESKIV

ANATOMIC AND FUNCTIONAL ANATOMIC AND FUNCTIONAL OF THE ESOPHAGUSOF THE ESOPHAGUS

The normal functions of the esophagus are simple - the transport The normal functions of the esophagus are simple - the transport of food from the pharynx to the stomach and the prevention of of food from the pharynx to the stomach and the prevention of reflux of gastric contents. Disease processes that affect either reflux of gastric contents. Disease processes that affect either function may result in profound clinical symptoms. function may result in profound clinical symptoms.

Some important anatomic features of the esophagus are Some important anatomic features of the esophagus are illustrated inillustrated in next sl next sl. The esophagus is a muscular tube that . The esophagus is a muscular tube that begins as a continuation of the pharynx at about the level of the begins as a continuation of the pharynx at about the level of the sixth cervical vertebra. It is a relatively mobile structure, fixed sixth cervical vertebra. It is a relatively mobile structure, fixed only at its proximal and distal ends. only at its proximal and distal ends. The trachea lies immediately The trachea lies immediately anterior to the esophagus from its origin in the neck to the anterior to the esophagus from its origin in the neck to the tracheal bifurcation at the level of the fifth thoracic vertebra. The tracheal bifurcation at the level of the fifth thoracic vertebra. The right and left recurrent laryngeal nerves ascend in grooves right and left recurrent laryngeal nerves ascend in grooves between the trachea and cervical esophagus, where they are between the trachea and cervical esophagus, where they are vulnerable to involvement by proximal esophageal tumors. Also vulnerable to involvement by proximal esophageal tumors. Also adjacent to the cervical esophagus are the right and left common adjacent to the cervical esophagus are the right and left common carotid arteries and part of the thyroid gland.carotid arteries and part of the thyroid gland.

Schematic Schematic representation of the representation of the esophagus illustrating esophagus illustrating

some importantsome important anatomic anatomic

relationships.relationships.

ANATOMIC AND FUNCTIONAL OF THE ESOPHAGUSANATOMIC AND FUNCTIONAL OF THE ESOPHAGUS Barium contrast examination of the normal esophagus reveals an indentation at the Barium contrast examination of the normal esophagus reveals an indentation at the

level of the fourth thoracic vertebra caused by the arch of the aorta. Just below the level of the fourth thoracic vertebra caused by the arch of the aorta. Just below the aortic arch, the anterior aspect of the esophagus may be narrowed slightly by the left aortic arch, the anterior aspect of the esophagus may be narrowed slightly by the left main bronchus. Below the left main bronchus, the left atrium lies just anterior to the main bronchus. Below the left main bronchus, the left atrium lies just anterior to the esophagus. Because of these intimate anatomic associations, any enlargement of the esophagus. Because of these intimate anatomic associations, any enlargement of the thyroid gland, carinal lymph nodes, or left atrium or aorta (aneurysm) can be thyroid gland, carinal lymph nodes, or left atrium or aorta (aneurysm) can be recognized by characteristic impressions on the barium-filled esophagus.recognized by characteristic impressions on the barium-filled esophagus.

Attempts to correlate the structural features of the distal esophagus with its Attempts to correlate the structural features of the distal esophagus with its remarkable function have resulted in confusion regarding the anatomy of this remarkable function have resulted in confusion regarding the anatomy of this segment. While the radiologist and physiologist can recognize a lower esophageal segment. While the radiologist and physiologist can recognize a lower esophageal sphincter (LES), prosectors have searched in vain for a corresponding anatomic sphincter (LES), prosectors have searched in vain for a corresponding anatomic sphincter.sphincter.

The physiological LES corresponds roughly with the esophageal ampulla observed on The physiological LES corresponds roughly with the esophageal ampulla observed on barium contrast examinations. The fluoroscopist recognizes this area both by its barium contrast examinations. The fluoroscopist recognizes this area both by its ability to remain contracted at rest and to dilate more than the remainder of the ability to remain contracted at rest and to dilate more than the remainder of the esophagus when distended with barium. The proximal border of the ampulla is esophagus when distended with barium. The proximal border of the ampulla is formed by a band of circular muscle called the upper. A ring or muscular ring. In formed by a band of circular muscle called the upper. A ring or muscular ring. In some individuals, the radiologist may identify the lower esophageal mucosal ring (also some individuals, the radiologist may identify the lower esophageal mucosal ring (also known as the В ring or Schatzki ring), which marks the distal border of the ampulla.known as the В ring or Schatzki ring), which marks the distal border of the ampulla.

The muscular coat of the proximal third of the esophagus is comprised predominantly The muscular coat of the proximal third of the esophagus is comprised predominantly of striated muscle, while that of the distal two-thirds is largely smooth muscle. of striated muscle, while that of the distal two-thirds is largely smooth muscle. Therefore, the esophagus is vulnerable to diseases affecting either type of muscle.Therefore, the esophagus is vulnerable to diseases affecting either type of muscle.

The vagus nerve innervates both the striated and the smooth muscle portions of the The vagus nerve innervates both the striated and the smooth muscle portions of the esophagus. Innervation to the distal esophagus and LES is carried in intramural esophagus. Innervation to the distal esophagus and LES is carried in intramural nerve plexuses. Because of this intramural innervation, distal thoracic truncal nerve plexuses. Because of this intramural innervation, distal thoracic truncal vagotomy has little effect on distal esophageal function. The esophagus also receives vagotomy has little effect on distal esophageal function. The esophagus also receives fibers from cervical and thoracic sympathetic ganglia. The venous drainage of the fibers from cervical and thoracic sympathetic ganglia. The venous drainage of the distal esophagus is by way of the gastric veins into the portal vein; therefore, distal esophagus is by way of the gastric veins into the portal vein; therefore, esophageal varices may develop as a consequence of portal hypertension.esophageal varices may develop as a consequence of portal hypertension.

Unlike the rest of the gut, the esophagus has no serosal layer. Surgeons claim that this Unlike the rest of the gut, the esophagus has no serosal layer. Surgeons claim that this contributes to the difficulty of esophageal surgery. Lack of a restraining serosa may contributes to the difficulty of esophageal surgery. Lack of a restraining serosa may also contribute to the local invasiveness of esophageal carcinoma.also contribute to the local invasiveness of esophageal carcinoma.

CLINICAL ANATOMY OF THE STOMACHCLINICAL ANATOMY OF THE STOMACH The size and shape of the stomach vary from moment to moment The size and shape of the stomach vary from moment to moment

depending on the volume of its contents and on body posture. For depending on the volume of its contents and on body posture. For clinical purposes, it is useful to divide this distensible organ into clinical purposes, it is useful to divide this distensible organ into four anatomic regions. The cardia is the portion of the stomach four anatomic regions. The cardia is the portion of the stomach immediately adjacent to the esophagus; the fundus is the region immediately adjacent to the esophagus; the fundus is the region that rises above the cardia. The body of the stomach extends that rises above the cardia. The body of the stomach extends from the fundus to the incisura angularis, an indentation on the from the fundus to the incisura angularis, an indentation on the lesser curvature that is best appreciated by barium contrast lesser curvature that is best appreciated by barium contrast examination. The antrum is the region beyond the incisura examination. The antrum is the region beyond the incisura angularis where the stomach turns horizontally toward the angularis where the stomach turns horizontally toward the pyloric sphincter.pyloric sphincter.

The histologist often can identify the anatomic region from which The histologist often can identify the anatomic region from which a gastric biopsy is obtained by the type of gastric glands present a gastric biopsy is obtained by the type of gastric glands present in the specimen. The cardiac region contains the cardiac glands, in the specimen. The cardiac region contains the cardiac glands, which are predominantly composed of mucous cells. The oxyntic which are predominantly composed of mucous cells. The oxyntic glands are found in the fundus and body of the stomach and glands are found in the fundus and body of the stomach and contain both chief (zymogen) cells, which secrete pepsinogens, contain both chief (zymogen) cells, which secrete pepsinogens, and parietal (oxyntic) cells, which secrete hydrochloric acid and and parietal (oxyntic) cells, which secrete hydrochloric acid and intrinsic factor. The gastric antrum contains the pyloric glands, intrinsic factor. The gastric antrum contains the pyloric glands, which include endocrine cells that produce gastrin. The surgeon which include endocrine cells that produce gastrin. The surgeon takes advantage of this relationship between gross and takes advantage of this relationship between gross and microscopic anatomy when designing an operation for peptic microscopic anatomy when designing an operation for peptic ulcer disease. For example, an antrectomy may be performed to ulcer disease. For example, an antrectomy may be performed to remove the gastrin-secreting mechanism of the stomach.remove the gastrin-secreting mechanism of the stomach.

CLINICAL ANATOMY OF THE DUODENUMCLINICAL ANATOMY OF THE DUODENUM

The duodenum may also be divided into four anatomic regions. The first portion of the The duodenum may also be divided into four anatomic regions. The first portion of the duodenum extends posteriorly and superiorly from the pylorus to the first duodenal flexure; it is duodenum extends posteriorly and superiorly from the pylorus to the first duodenal flexure; it is entirely intraperitoneal and normally assumes a characteristic conical shape when distended with entirely intraperitoneal and normally assumes a characteristic conical shape when distended with barium (duodenal bulb). The second portion of the duodenum extends vertically downward from barium (duodenal bulb). The second portion of the duodenum extends vertically downward from the first to the second duodenal flexure. Its medial wall is adjacent to the head of the pancreas, the first to the second duodenal flexure. Its medial wall is adjacent to the head of the pancreas, which when enlarged by carcinoma or pancreatitis, produces a tell tale impression on the which when enlarged by carcinoma or pancreatitis, produces a tell tale impression on the barium-filled second duodenal portion.barium-filled second duodenal portion.

The ampulla of Vater, the intestinal opening of the major pancreatic duct and common bile duct, The ampulla of Vater, the intestinal opening of the major pancreatic duct and common bile duct, is located in this duodenal segment. The third portion is the horizontal segment situated just is located in this duodenal segment. The third portion is the horizontal segment situated just anterior to the inferior vena cava and aorta; the superior mesenteric artery and vein lie anterior anterior to the inferior vena cava and aorta; the superior mesenteric artery and vein lie anterior to this duodenal segment. The fourth portion of the duodenum is the ascending segment that to this duodenal segment. The fourth portion of the duodenum is the ascending segment that begins just to the left of the aorta. A fibromuscular ligament arising from the right cms of the begins just to the left of the aorta. A fibromuscular ligament arising from the right cms of the diaphragm (ligament of Treitz) attaches to the small intestine at the duodenojejunal flexure, diaphragm (ligament of Treitz) attaches to the small intestine at the duodenojejunal flexure, which delimits the end of the duodenum and the beginning of the jejunum. Except for a small which delimits the end of the duodenum and the beginning of the jejunum. Except for a small segment near the duodenojejunal flexure, the second, third, and fourth portions of the duodenum segment near the duodenojejunal flexure, the second, third, and fourth portions of the duodenum are entirely retro-peritoneal.are entirely retro-peritoneal.

The duodenum is histologically distinguished from the remainder of the small intestine by the The duodenum is histologically distinguished from the remainder of the small intestine by the presence of Brunner’s glands in the duodenal submucosa; these glands secrete a viscous, highly presence of Brunner’s glands in the duodenal submucosa; these glands secrete a viscous, highly alkaline fluid. The blood supply to the stomach and duodenum is generous. The stomach is alkaline fluid. The blood supply to the stomach and duodenum is generous. The stomach is supplied by large vessels arising from all branches of the celiac artery. The duodenum receives supplied by large vessels arising from all branches of the celiac artery. The duodenum receives blood from the superior pancreaticoduodenal branches of the gastroduodenal artery and the blood from the superior pancreaticoduodenal branches of the gastroduodenal artery and the inferior pancreaticoduodenal branches of the superior mesenteric artery. Not surprisingly, inferior pancreaticoduodenal branches of the superior mesenteric artery. Not surprisingly, bleeding frequently accompanies ulceration of the stomach and duodenum.bleeding frequently accompanies ulceration of the stomach and duodenum.

The vagal trunks applied to the anterior and posterior surfaces of the distal esophagus provide The vagal trunks applied to the anterior and posterior surfaces of the distal esophagus provide parasympathetic innervation to the entire stomach. These vagal trunks also give off hepatic parasympathetic innervation to the entire stomach. These vagal trunks also give off hepatic branches and celiac branches that supply the small bowel and other abdominal viscera. This branches and celiac branches that supply the small bowel and other abdominal viscera. This anatomic distribution is important to the surgeon who may wish to spare hepatic, celiac, or anatomic distribution is important to the surgeon who may wish to spare hepatic, celiac, or pyloric vagal branches when performing a selective or proximal gastric vagotomy for treatment pyloric vagal branches when performing a selective or proximal gastric vagotomy for treatment of peptic ulcer disease. of peptic ulcer disease.

GENERAL ANATOMIC AND

FUNCTIONAL OF THE SMALL

INTESTINE

The most remarkable feature of the small intestine is its enormous surface area, which is conferred not so

much by its length as by its multitude of circumferential folds, villi, and microvilli. The anatomic regions of

the small intestine, designated as duodenum, jejunum, and ileum, have no clear boundaries with respect to

absorptive cell characteristics; functionally their similarities are greater than their differences. Indeed,

regional specialization exists only with respect to vitamin B12 and conjugated bile salts, which are both

absorbed preferentially in the distal ileum. Although absorption of all other nutrients appears to be greater in

proximal sites, absorption takes place along the entire length of the intestine. In addition, the small intestine

has an enormous reserve capacity and can fully compensate for losses of up to one-half its length. The

intestine is more than a conduit for nutrients. Although most of the enzymatic digestion of carbohydrates,

proteins, and lipids takes place in the small intestinal lumen before their uptake, optimum absorption of both

protein and carbohydrate is closely linked to an ultimate phase of hydrolysis that occurs within the intestinal

brush border. Dietary fat is digested in the lumen and not further hydrolyzed in the intestinal cells. However,

within these cells, absorbed fat is resynthesized to complex lipids and combined with transport proteins for

delivery into the lymph.The major manifestations of small intestinal diseases are malabsorption of nutrients

and abnormalities in water and electrolyte transport.

ANATOMIC AND FUNCTIONAL OF THE COLONANATOMIC AND FUNCTIONAL OF THE COLON The ileal effluent entering the colon consists of water, electrolytes, unabsorbed gastrointestinal The ileal effluent entering the colon consists of water, electrolytes, unabsorbed gastrointestinal

secretions, cellular debris, and undigested food residue. The colon has no digestive function per se; secretions, cellular debris, and undigested food residue. The colon has no digestive function per se; its principal roles are to assist in maintaining the body’s electrolyte and water balance and to excrete its principal roles are to assist in maintaining the body’s electrolyte and water balance and to excrete the unabsorbed remains or feces by means of its absorptive, secretory, storage, and excretory the unabsorbed remains or feces by means of its absorptive, secretory, storage, and excretory functions. Sodium, chloride, and water are absorbed, and potassium and bicarbonate are secreted. functions. Sodium, chloride, and water are absorbed, and potassium and bicarbonate are secreted. The importance of the colon in sodium absorption is demonstrated by the fact that patients with an The importance of the colon in sodium absorption is demonstrated by the fact that patients with an intact intestine can consume a low-sodium diet (10 mEq/day) for months without adverse effects, intact intestine can consume a low-sodium diet (10 mEq/day) for months without adverse effects, whereas individuals with ileostomy on a 10 mEq per day sodium diet develop symptoms and signs of whereas individuals with ileostomy on a 10 mEq per day sodium diet develop symptoms and signs of sodium depletion within 3 to 5 days. Absorption and secretion of electrolytes and water occur sodium depletion within 3 to 5 days. Absorption and secretion of electrolytes and water occur principally in the right half of the colon; the ability of the colon to perform these functions decreases principally in the right half of the colon; the ability of the colon to perform these functions decreases toward the rectum. The undigested food residue is primarily that portion of plant cells contained toward the rectum. The undigested food residue is primarily that portion of plant cells contained principally in cereals that consists of nonstarch polysaccarides and lignin (an aromatic polymer); the principally in cereals that consists of nonstarch polysaccarides and lignin (an aromatic polymer); the intestinal tract is devoid of enzymes to digest these substances known as dietary fiber. The nonstarch intestinal tract is devoid of enzymes to digest these substances known as dietary fiber. The nonstarch polysaccarides are degraded by colonic bacteria to short-chain fatty acids, other products, and gases polysaccarides are degraded by colonic bacteria to short-chain fatty acids, other products, and gases (e.g., methane, carbon dioxide, and hydrogen), while the lignin remains practically intact. These (e.g., methane, carbon dioxide, and hydrogen), while the lignin remains practically intact. These products of bacterial degradation, except for the gases, give bulk to the stool by imbibing water and products of bacterial degradation, except for the gases, give bulk to the stool by imbibing water and are laxative in effect. In the western world, the average normal fecal output is up to 200 gm per day are laxative in effect. In the western world, the average normal fecal output is up to 200 gm per day and contains 100 to 150 ml of water, up to 5 mEq of sodium, 7 to 15 mEq of potassium, 2 mEq of and contains 100 to 150 ml of water, up to 5 mEq of sodium, 7 to 15 mEq of potassium, 2 mEq of chloride, and 3 mEq of bicarbonate. The normal colon has the capacity to absorb about 6 liters of chloride, and 3 mEq of bicarbonate. The normal colon has the capacity to absorb about 6 liters of water and about 800 mEq of sodium per day. The storage and excretory functions of the colon water and about 800 mEq of sodium per day. The storage and excretory functions of the colon depend on coordinated colonic motor activity. Nonpropulsive, segmental contractions that probably depend on coordinated colonic motor activity. Nonpropulsive, segmental contractions that probably produce the haustra move the bowel contents forward and backward over short segments of mucosa, produce the haustra move the bowel contents forward and backward over short segments of mucosa, thus enhancing absorption. Periodically, a peristalitic contraction propels the contents forward thus enhancing absorption. Periodically, a peristalitic contraction propels the contents forward either for a short distance or on into the sigmoid colon or rectum. Distention of the rectum induces a either for a short distance or on into the sigmoid colon or rectum. Distention of the rectum induces a desire to defecate, which can be overcome by voluntary contraction of the internal and external anal desire to defecate, which can be overcome by voluntary contraction of the internal and external anal sphincterssphincters

GAS PATTERNSGAS PATTERNS

NORMAL ABDOMINAL RADIOGRAPHSNORMAL ABDOMINAL RADIOGRAPHS In the supine abdominal radiograph gas is normally present in the body of the In the supine abdominal radiograph gas is normally present in the body of the

stomach and in variable amounts in the transverse and other parts of the stomach and in variable amounts in the transverse and other parts of the colon. It is also present in small amounts in the small intestine of adults. colon. It is also present in small amounts in the small intestine of adults. Normal gas-fluid levels are usually seen in the gastric fundus on erect Normal gas-fluid levels are usually seen in the gastric fundus on erect radiographs and occasionally in the first part of the duodenum and in the radiographs and occasionally in the first part of the duodenum and in the caecum. In infants and children gaseous distension of the stomach and of the caecum. In infants and children gaseous distension of the stomach and of the intestines is a common feature. In infants in particular this is largely due to intestines is a common feature. In infants in particular this is largely due to swallowed air. Supine abdominal radiographs occasionally show apparent soft swallowed air. Supine abdominal radiographs occasionally show apparent soft tissue masses in the gastric fundus or duodenal loop; these are well-recognised tissue masses in the gastric fundus or duodenal loop; these are well-recognised ‘pseudo-tumours’ and are due to normal fluid collections gravitating to these ‘pseudo-tumours’ and are due to normal fluid collections gravitating to these dependent areas.dependent areas.

ABNORMAL GAS PATTERNSABNORMAL GAS PATTERNS Abnormal gas patterns in abdominal radiographs may be conveniently classified into:Abnormal gas patterns in abdominal radiographs may be conveniently classified into:

excessive intestinal gasexcessive intestinal gas abnormal contour of gas-containing loopsabnormal contour of gas-containing loops extraluminal gas.extraluminal gas.

Excessive intestinal gas Excessive intestinal gas

Causes Radiological featuresPhysiological Air-swallowing,

usually in childrenNon-specific gaseous distension. No consistent end-point to

suggest obstruction

Mechanical obstruction Small bowel, e.g. adhesions,

hernia, Crohn’s disease

Gaseous distension of loops of small bowel which lie centrally. Valvulae conniventes visible. Short fluid levels on erect film.

Large bowel, e.g. carcinoma, diverticular disease with stricture

Distension of peripherally situated large bowel, proximal to obstruction. Haustra visible. Longer fluid levels than in small bowel

Volvulus of the caecum, sigmoid Specific radiological signs. Extremely dilated loops extending upwards from normal site of these structures to lie in upper quadrants. Very long fluid levels in erect film

Non-mechanical obstruction (or pseudo-obstruction).Generalised ileus, e.g. following surgery, peritonitis, metabolic disorders

Large and small bowel distended. May resemble mechanical obstruction

Localised ileus, e.g. appendicitis, pancreatitis, abscess, ischaemia

Single loop of dilated bowel (sentinel loop). Speckled gas in abscess

Abnormal contour of gas-containing Abnormal contour of gas-containing loops loops

Causes Radiological features

Crohn’s disease Affects small or large bowel, or both. Stricture may be visible,

or irregularity of mucosa due to ulceration May show

signs of obstruction or toxic megacolon (see below)

Ulcerative colitis Narrowed, featureless empty colon. Pseudopolypi may be

visible as filling defects. Gross dilatation - ‘toxic

megacolon’ is a dangerous complication and predisposes

to perforation

Ischaemia Dilated bowel, thickened wall with areas of oedema ‘thumb-

printing’. Ileus, with signs of obstruction

Intrinsic masses Tumours and intussusception may be outlined by gas

Displaced loops Large non-alimentary abdominal masses, e.g. enlarged spleen,

may displace or indent gas-filled loops of otherwise

normal bowel

Extraluminal gas Extraluminal gas

Causes Radiological featuresIntraperitonealPerforation of a hollow viscus

Variable amounts of gas, from small crescent under diaphragm (erect film) to gross peritoneal distension

Subphrenic abscess Air-fluid level under diaphragm. Adjacent lung base consolidation. Confirm with ultrasound

Bowel wallInfarction, necrotising enterocolitis in

infants

Linear streaks of gas in bowel wall. May coalesce or outline portal vein radicles

Pneumatosis coli Blebs of gas in colon wall. Symptoms may mimic carcinoma. Usually elderly patient with airways obstruction

Biliary treeAfter sphincterotomy or anastomosis

between biliary tree and bowel

Branching gas pattern in liver (bile ducts). Usually lie centrally in liver; gas in portal vein radicles extends more peripherally

Erosion of gallstone into small bowel; erosion of duodenal ulcer into biliary tree; pancreatic neoplasm; gas-forming infection

Small bowel obstruction (‘gallstone ileus’) and opaque calculus may be visible in intestine with gas in biliary tree. Other causes listed do not cause intestinal obstruction

Genitourinary tractFistula, e.g. trauma, postoperative,

Crohn’s disease

Gas may outline urinary bladder, ureters and collecting systems. Differential diagnosis: gas-forming infection in diabetic patients

ABDOMINAL CALCIFICATIONABDOMINAL CALCIFICATION

Many structures in the abdomen calcify, especially in Many structures in the abdomen calcify, especially in older subjects; most of these are of no clinical older subjects; most of these are of no clinical significance. They include the walls of blood vessels, significance. They include the walls of blood vessels, lymph nodes and costal cartilages. Calcification may lymph nodes and costal cartilages. Calcification may also occur in pathological states but may be also occur in pathological states but may be discovered coincidentally. Gallstones and prostatic discovered coincidentally. Gallstones and prostatic calcification fall into this category. Those that are calcification fall into this category. Those that are often associated with symptoms include calcified often associated with symptoms include calcified urinary calculi, pancreatic calcification in chronic urinary calculi, pancreatic calcification in chronic pancreatitis, and calcification occurring in abdominal pancreatitis, and calcification occurring in abdominal tumours tumours

RADIOLOGICAL EXAMINATION OF THE GASTROINTESTINAL RADIOLOGICAL EXAMINATION OF THE GASTROINTESTINAL TRACTTRACT

Contrast studies of the gastrointestinal tract and endoscopic diagnostic techniques play Contrast studies of the gastrointestinal tract and endoscopic diagnostic techniques play complementary roles in the investigation of alimentary tract symptoms. How these different methods complementary roles in the investigation of alimentary tract symptoms. How these different methods are deployed in different hospitals depends to a large extent on the availability and accessibility of are deployed in different hospitals depends to a large extent on the availability and accessibility of endoscopy. Hospitals with comprehensive endoscopy facilities and ‘open access’ policies tend to use endoscopy. Hospitals with comprehensive endoscopy facilities and ‘open access’ policies tend to use this technique as the first-line investigation in patients with gastrointestinal symptoms. This has been this technique as the first-line investigation in patients with gastrointestinal symptoms. This has been accompanied by a decline in the numbers of barium studies carried out in the same hospitals. In accompanied by a decline in the numbers of barium studies carried out in the same hospitals. In general, patients complaining of dysphagia can be investigated using either endoscopy or radiology: general, patients complaining of dysphagia can be investigated using either endoscopy or radiology: dyspepsia is investigated by endoscopy; colonic symptoms are investigated using barium techniques, dyspepsia is investigated by endoscopy; colonic symptoms are investigated using barium techniques, followed by colonoscopy for further clarification and biopsy; upper gastrointestinal bleeding followed by colonoscopy for further clarification and biopsy; upper gastrointestinal bleeding (haematemesis and melaena) is investigated with endoscopy; the small bowel is examined by means (haematemesis and melaena) is investigated with endoscopy; the small bowel is examined by means of a specialised barium technique. There will be many local variations in the way that some of these of a specialised barium technique. There will be many local variations in the way that some of these investigations are used.investigations are used.

BARIUM EXAMINATIONSBARIUM EXAMINATIONS Barium sulphate suspensions are specially formulated for use in different parts of the alimentary Barium sulphate suspensions are specially formulated for use in different parts of the alimentary

tract. Whether they are taken orally or introduced through simall bowel or rectal tubes, they are tract. Whether they are taken orally or introduced through simall bowel or rectal tubes, they are accompanied by gas (carbon dioxide) releasing agents or air insuflation to produce what is known as accompanied by gas (carbon dioxide) releasing agents or air insuflation to produce what is known as air contrast or double contrast. This allows detection of small mucosal lesions as well as improving air contrast or double contrast. This allows detection of small mucosal lesions as well as improving the accuracy of these techniques in detecting masses, polyps, strictures, infiltrations and surface the accuracy of these techniques in detecting masses, polyps, strictures, infiltrations and surface erosions and ulceration.erosions and ulceration.

All barium examinations are carried out under fluoroscopic control to optimise mucosal barium All barium examinations are carried out under fluoroscopic control to optimise mucosal barium coating and gaseous distension. Assessment of gut distensibility and motility can also be made during coating and gaseous distension. Assessment of gut distensibility and motility can also be made during fluoroscopy. Biopsy techniques have been used in conjunction with barium studies of the oesophagus fluoroscopy. Biopsy techniques have been used in conjunction with barium studies of the oesophagus but have not gained widespread acceptance. Endoscopic ultrasound techniques are becoming but have not gained widespread acceptance. Endoscopic ultrasound techniques are becoming established and have been shown to be useful in the oesophagus, stomach and rectum. Contrast established and have been shown to be useful in the oesophagus, stomach and rectum. Contrast examination of the small bowel will be discussed in a later section in this lecture.examination of the small bowel will be discussed in a later section in this lecture.

In this section it is appropriate to discuss radiology of the alimentary tract according to the clinical In this section it is appropriate to discuss radiology of the alimentary tract according to the clinical presentation - dysphagia, dyspepsia, bleeding, symptoms suggesting small bowel disease, and large presentation - dysphagia, dyspepsia, bleeding, symptoms suggesting small bowel disease, and large bowel disorders.bowel disorders.

DYSPHAGIADYSPHAGIA

Causes Radiological features

Post-cricoid carcinoma Irregular narrowing; mass displacing larynx forwards

Pharyngeal diverticulum Variable size, arising posteriorly

Oesophageal web Characteristic appearance; associated with iron-deficiency anaemia

Malignant stricture May be primary oesophageal cancer or invasion by bronchial or mediastinal tumour. Characteristic appearance - irregular narrowing, ‘shouldering’, partial or complete obstruction

Stricture secondary to reflux oesophagitis and hiatus hernia complex

Reflux shown during fluoroscopy; mucosal ulceration, hiatus hernia; strictures tend to be smooth but may mimic carcinoma

Achalasia Generalised motility defect with dysfunction of cardia causing obstruction and sometimes gross dilatation of oesophagus, with food and liquid residue

Miscellaneous causes:corrosive strictures

Severe ulceration initially. Tendency to perforate

moniliasis, herpes infection Opportunistic infection. Severe ulceration and pain

systemic sclerosis Impaired peristalsis

neurological disorders Swallowing difficulties with aspiration into lungs

This is a common symptom. Its radiological assessment often requires a rapid sequence of radiographs or video recording during fluoroscopy, so that the swallowing function can be studied in detail from the oropharynx to the gastric cardia. The common causes of dysphagia and their radiological features are summarised in Table

DyspepsiaDyspepsia This term is used to describe upper abdominal symptoms arising from a variety of This term is used to describe upper abdominal symptoms arising from a variety of

different conditions. Epigastric pain, with or without a relationship to food, is an different conditions. Epigastric pain, with or without a relationship to food, is an extremely common symptom. Peptic ulceralion, hiatus hernia with gastro-oesophageal extremely common symptom. Peptic ulceralion, hiatus hernia with gastro-oesophageal reflux, gastric neoplasm and diseases of the biliary tract (e.g. gallstones) and pancreas reflux, gastric neoplasm and diseases of the biliary tract (e.g. gallstones) and pancreas (e.g. chronic pancreatitis, carcinoma) all tend to cause similar symptoms. It is possible to (e.g. chronic pancreatitis, carcinoma) all tend to cause similar symptoms. It is possible to distinguish between these conditions to some extent on the basis of symptom complexes, distinguish between these conditions to some extent on the basis of symptom complexes, particularly their relationship to meals. Persistence of symptoms despite adequate particularly their relationship to meals. Persistence of symptoms despite adequate medical treatment, weight loss, vomiting, blood loss (haematemesis and melaena), medical treatment, weight loss, vomiting, blood loss (haematemesis and melaena), persistent pain with radiation away from the typical site of peptic ulcer or gallstone pain persistent pain with radiation away from the typical site of peptic ulcer or gallstone pain are all features that give cause for concern. In this situation the patient should be are all features that give cause for concern. In this situation the patient should be investigated intensively, using endoscopy as the first investigation. If endoscopy is investigated intensively, using endoscopy as the first investigation. If endoscopy is negative, radiological techniques, including plain abdominal radiographs, upper negative, radiological techniques, including plain abdominal radiographs, upper gastrointestinal barium studies and ultrasonography, are used, depending on the gastrointestinal barium studies and ultrasonography, are used, depending on the symptom complex. Ultrasonography is useful for the detection of biliary and pancreatic symptom complex. Ultrasonography is useful for the detection of biliary and pancreatic disease; CT may be added to complete the investigations by outlining areas not disease; CT may be added to complete the investigations by outlining areas not demonstrated by ultrasonography, e.g. the retroperitoneal planes.Uncomplicated demonstrated by ultrasonography, e.g. the retroperitoneal planes.Uncomplicated dyspepsia which is short lived is usually managed conservatively (particularly in young dyspepsia which is short lived is usually managed conservatively (particularly in young adults) using one of the many anti-dyspepsia drug regimens. The decision to investigate adults) using one of the many anti-dyspepsia drug regimens. The decision to investigate this common problem depends on the availability of endoscopy services. There is, this common problem depends on the availability of endoscopy services. There is, however, some debate about the appropriateness of the current widespread use of however, some debate about the appropriateness of the current widespread use of endoscopy in this particular clinical circumstance.endoscopy in this particular clinical circumstance.

DyspepsiaDyspepsia

Cause Radiological features

Oesophageal disease hiatus hernia

complex

Superfici.il mucosal ulceration in the oesophagus indicates oesophagitis. Reflux may be detected but barium studies are less sensitiv e than endoscopy or pH studies. Strictures may develop and may be indistinguishable from malignant strictures

Gastric abnormalities

ulceration

Barium collection in crater. Radiating folds of mucosa to edge of crater. Surrounding deformity and oedema. Heal to form distinctive scars. May be malignant from outset. Careful endoscopic follow-up necessary, with biopsies

Polip(s) Multiple polyps in body of stomach form part of chronic gastritis spectrum - usually hyperplastic in nature, and benign. Adenomatous polyps, usually in antrum, may be premalignant lesion(s). Should be removed. Other types of polyps may be part of familial polyposis syndromes

Cancer Characteristic signs in advanced disease. Either ulcerating or polypoid, or mixture of both. Early or superficial cancers resemble benign ulcers but with specific signs such as ‘clubbed’ mucosal folds and geographical areas of very superficial ulceration

Non-mucosal tumours

Usually large and may have surface ulceration or excavation. Exogastric extension. May be leiomyoma, sarcoma or lymphoma

Duodenal disease:e.g. alceration

Characteristic ulcer craler(s) in first part of duodenum, with deformity. Atypical signs in Crohn’s disease and Zollinger-Ellison syndrome

BARIUM MEALBARIUM MEAL The standard double-contrast study of the upper gastrointestinal tract includes views of The standard double-contrast study of the upper gastrointestinal tract includes views of

the oesophagus, stomach and duodenum. The examination is carried out following a the oesophagus, stomach and duodenum. The examination is carried out following a period of starvation; peristalsis is temporarily abolished using an injection of glucagon period of starvation; peristalsis is temporarily abolished using an injection of glucagon or an atropine-like agent. This enhances mucosal coating with barium suspension and or an atropine-like agent. This enhances mucosal coating with barium suspension and allows detection of small mucosal lesions, e.g. erosions and polyps. The radiographs allows detection of small mucosal lesions, e.g. erosions and polyps. The radiographs obtained are examined for evidence of ulceration, deformity, infiltration, stricture obtained are examined for evidence of ulceration, deformity, infiltration, stricture formation, external compression or displacement, and obstruction. Some of the formation, external compression or displacement, and obstruction. Some of the radiological abnormalities that may be found are summarised in Table 5.radiological abnormalities that may be found are summarised in Table 5.

The major advantage of endoscopy in the investigation of alimentary disorders is the The major advantage of endoscopy in the investigation of alimentary disorders is the ability of the operator to obtain biopsies of lesions or suspicious mucosal abnormalities. ability of the operator to obtain biopsies of lesions or suspicious mucosal abnormalities. Sources of bleeding can also be identified accurately. Endoscopy is not without Sources of bleeding can also be identified accurately. Endoscopy is not without complications and it has been claimed that good barium studies are as accurate as complications and it has been claimed that good barium studies are as accurate as endoscopy in the detection of significant lesions.endoscopy in the detection of significant lesions.

What has become apparent over recent years is that many benign and malignant What has become apparent over recent years is that many benign and malignant diseases of the gastrointestinal tract cause similar or identical radiological signs, and that diseases of the gastrointestinal tract cause similar or identical radiological signs, and that some benign lesions become, or harbour, malignant disease. Disorders such as achalasia, some benign lesions become, or harbour, malignant disease. Disorders such as achalasia, peptic and corrosive strictures of the oesophagus, gastric ulcers and certain non-peptic and corrosive strictures of the oesophagus, gastric ulcers and certain non-epithelial sub-mucosal tumours, such as leiomyomas, predispose to, or undergo, epithelial sub-mucosal tumours, such as leiomyomas, predispose to, or undergo, malignant transformation into malignant tumours. Therefore direct inspection of the malignant transformation into malignant tumours. Therefore direct inspection of the lesions, obtaining biopsies where necessary, is an accepted way of following up some lesions, obtaining biopsies where necessary, is an accepted way of following up some lesions such as gastric ulcers. It is also known that malignant ulcers undergo cyclical lesions such as gastric ulcers. It is also known that malignant ulcers undergo cyclical healing changes and may therefore mimic benign ulcers.healing changes and may therefore mimic benign ulcers.

Finally, benign ulcers may cause marked localised fibrosis and deformity when they Finally, benign ulcers may cause marked localised fibrosis and deformity when they heal. This change is usually permanent and should not be the sole justification for heal. This change is usually permanent and should not be the sole justification for further follow-up using barium studies.further follow-up using barium studies.

GASTROINTESTINAL BLEEDINGGASTROINTESTINAL BLEEDING Bleeding may be the first manifestation and presenting feature of gastrointestinal disease. The clinical Bleeding may be the first manifestation and presenting feature of gastrointestinal disease. The clinical

picture may vary from severe haematemesis to anaemia due to occult blood loss (e.g. cancer of the stomach picture may vary from severe haematemesis to anaemia due to occult blood loss (e.g. cancer of the stomach or colon), melaena or frank rectal bleeding. Careful questioning may pin-point other symptoms, and or colon), melaena or frank rectal bleeding. Careful questioning may pin-point other symptoms, and clinical examination may reveal signs that help lo localise the cause of the bleeding. Very occasionally no clinical examination may reveal signs that help lo localise the cause of the bleeding. Very occasionally no cause is found after exhaustive investigation and these patients may require exploratory operations.cause is found after exhaustive investigation and these patients may require exploratory operations.

Endoscopic techniques are the preferred method of investigation because the sources of bleeding, both in Endoscopic techniques are the preferred method of investigation because the sources of bleeding, both in the upper gastrointestinal tract and in the colon, can be identified.the upper gastrointestinal tract and in the colon, can be identified.

Barium studies may show the causal abnormality but may also show unrelated diseases, which may cause Barium studies may show the causal abnormality but may also show unrelated diseases, which may cause confusion. Barium persisting in the alimentary tract may preclude the use of more effective investigations, confusion. Barium persisting in the alimentary tract may preclude the use of more effective investigations, such as isotope-labelled red blood cell scans or selective coeliac and mesenteric angiography, to localise such as isotope-labelled red blood cell scans or selective coeliac and mesenteric angiography, to localise sites of bleeding beyond the reach of diagnostic endoscopy, or when the latter is ‘negative’. Table 6 lists sites of bleeding beyond the reach of diagnostic endoscopy, or when the latter is ‘negative’. Table 6 lists some causes of upper gastrointestinal bleeding and their radiological features. It is important to remember some causes of upper gastrointestinal bleeding and their radiological features. It is important to remember that bleeding may arise in the small bowel or in the caecum; these areas are not easily accessible during that bleeding may arise in the small bowel or in the caecum; these areas are not easily accessible during endoscopy. Further more, bleeding may be intermittent, and may vary in severity from sub-clinical to endoscopy. Further more, bleeding may be intermittent, and may vary in severity from sub-clinical to catastrophic and life threatening. All diagnostic methods are more accurate during active bleeding. catastrophic and life threatening. All diagnostic methods are more accurate during active bleeding. Angiography must be carried out when bleeding is brisk (a rate of over 5 ml/min is often quoted); isotope-Angiography must be carried out when bleeding is brisk (a rate of over 5 ml/min is often quoted); isotope-labelled red blood cell scans may detect slower rates of bleeding but are anatomically less precise.labelled red blood cell scans may detect slower rates of bleeding but are anatomically less precise.

Selective coeliac and mesenteric angiography is time consuming and is rendered more difficult and Selective coeliac and mesenteric angiography is time consuming and is rendered more difficult and hazardous if the patient’s general condition is deteriorating due to the rate of blood loss. The technique hazardous if the patient’s general condition is deteriorating due to the rate of blood loss. The technique may show a vascular lesion or demonstrate extravasation of contrast medium into the bowel lumen.may show a vascular lesion or demonstrate extravasation of contrast medium into the bowel lumen.

In a patient with portal hypertension it may be important to demonstrate the patency of the portal vein if In a patient with portal hypertension it may be important to demonstrate the patency of the portal vein if shunt procedures are being considered. Delayed radiographs will demonstrate the venous phase of an shunt procedures are being considered. Delayed radiographs will demonstrate the venous phase of an angiogram and will outline draining and collateral veins. This technique has superseded the hazardous angiogram and will outline draining and collateral veins. This technique has superseded the hazardous direct approach of splenoportography which involved direct needle puncture of the spleen.direct approach of splenoportography which involved direct needle puncture of the spleen.

One cause of rectal bleeding, particularly in childhood, is a Meckel’s diverticulum. Because this contains One cause of rectal bleeding, particularly in childhood, is a Meckel’s diverticulum. Because this contains gastric mucosa which ulcerates and bleeds, it is readily detectable using a technetium isotope scan. The gastric mucosa which ulcerates and bleeds, it is readily detectable using a technetium isotope scan. The ectopic gastric mucosa is shown as a localised area of increased isotope activity, usually lying centrally in ectopic gastric mucosa is shown as a localised area of increased isotope activity, usually lying centrally in the abdomen. the abdomen.

Upper gastrointestinal bleeding Upper gastrointestinal bleeding

Cause Radiological features OesophagusVarices due to portal hypertension

Serpiginous filling detects on barium studies of the lower oesophagus

Mucosal tear following vomiting (Mallory-Weiss lesion)

Tears rarely shown radiologically. Endoscopy preferred

Oesophagitis, .ill causes Stomach

Endoscopy more sensitive. Barium studies may show ulceration

Erosions Characteristic multiple ‘target’ lesions. Acute or chronic gastritis

Ulcer, tumour, varices Duodenum

Characteristic appearances. Varices here usually accompanied by varices in the oesophagus, though not invariable

Ulceralion, invasion from adjacent tumour Characteristic findings in duodenal ulceration; signs of malignant infiltration also characteristic

THE SMALL INTESTINETHE SMALL INTESTINE The usual indications for investigating the small intestine are:The usual indications for investigating the small intestine are:

abdominal pain, weight loss, diarrhoea symptoms suggesting inflammatory disease;abdominal pain, weight loss, diarrhoea symptoms suggesting inflammatory disease; colicky abdominal pain, distension, vomiting - symptoms suggesting obstruction, colicky abdominal pain, distension, vomiting - symptoms suggesting obstruction,

which may be intermittent;which may be intermittent; anaemia, malabsorption - caused by a variety of small bowel disorders.anaemia, malabsorption - caused by a variety of small bowel disorders.

Abdominal radiographs may show signs of small bowel obstruction but the cause may Abdominal radiographs may show signs of small bowel obstruction but the cause may not be apparent. Evidence of inflammatory disease in the colon is helpful (Table 2).not be apparent. Evidence of inflammatory disease in the colon is helpful (Table 2).

Small bowel contrast studies may be a continuation of a barium meal (a ‘follow-through’ Small bowel contrast studies may be a continuation of a barium meal (a ‘follow-through’ study) although the high density barium contrast agent used specifically for double-study) although the high density barium contrast agent used specifically for double-contrast studies of the oesophagus, stomach and duodenum may give poor images of the contrast studies of the oesophagus, stomach and duodenum may give poor images of the small bowel. F:or the small bowel a large volume of relatively low density (semi-small bowel. F:or the small bowel a large volume of relatively low density (semi-transparent) barium suspension is more appropriate.transparent) barium suspension is more appropriate.

A more detailed study of the small bowel may be indicated if a follow-through A more detailed study of the small bowel may be indicated if a follow-through examination is inconclusive; this consists of administering the barium suspension via a examination is inconclusive; this consists of administering the barium suspension via a catheter introduced through the mouth into the proximal small intestine (small bowel catheter introduced through the mouth into the proximal small intestine (small bowel enema, or enteroclysis). This method has some well-documented advantages but is more enema, or enteroclysis). This method has some well-documented advantages but is more invasive. Fluoroscopy is used to determine the optimal infusion rate of contrast agent invasive. Fluoroscopy is used to determine the optimal infusion rate of contrast agent and allows ‘spot films’ of areas of interest to be obtained during the infusion.and allows ‘spot films’ of areas of interest to be obtained during the infusion.

The radiological features of some common small bowel disorders are summarised in The radiological features of some common small bowel disorders are summarised in Table .Table .

Small bowel disorders Small bowel disorders Cause Radiological features

Crohn’s disease Signs of bowel inflammation - characteristic fissuring or ‘rose-thorn’ ulcers, nodular or ‘cobble-stone’ mucosa, strictures, thickened bowel wall, adherence of adjacent loops, fistulae to adjoining structures, ‘skip’ lesions, dilated and obstructed loops of bowel, involvement of stomach, duodenum and colon. Terminal ileum is commonly affected, but disease may be extensive

Obstruction due to causes other than inflammation

Small bowel contrast studies usually localise site of obstruction provided proximal loops are not too distended. Adhesions produce characteristic deformities of affected loops, especially when using small bowel enema technique

Malabsorphion problems, other than those caused by. inflammatory disease

Coeliac syndrome causes non-specific dilatation of small bowel loops in severe cases but small bowel biopsy is much more specific. Jejunnl diverticulosis , blind loops, fislulae and strictures may all cause malabsorption and are detectable on contrast studies

THE LARGE INTESTINETHE LARGE INTESTINE Symptoms such as alterecd bowel habit, rectal bleeding, abdominal pain, weight Symptoms such as alterecd bowel habit, rectal bleeding, abdominal pain, weight

loss and anaemia may indicate serious colonic disease. Colonoscopy and barium loss and anaemia may indicate serious colonic disease. Colonoscopy and barium studies are complementary and equally useful but their deployment depends to a studies are complementary and equally useful but their deployment depends to a large extent on the availability of colonoscopy services. Many clinicians use the large extent on the availability of colonoscopy services. Many clinicians use the barium enema as the first-line diagnostic investigation and either combine this with barium enema as the first-line diagnostic investigation and either combine this with flexible fibreoptic sigmoidoscopy or reserve a full colonoscopy for those instances flexible fibreoptic sigmoidoscopy or reserve a full colonoscopy for those instances where a barium study is inconclusive or where a lesion shown radio-logically where a barium study is inconclusive or where a lesion shown radio-logically requires further direct examination and biopsy.requires further direct examination and biopsy.

Barium studies require full bowel preparation using one of a variety of cleansing Barium studies require full bowel preparation using one of a variety of cleansing techniques (faecal residue may mimic polyps or tumours). A double-contrast techniques (faecal residue may mimic polyps or tumours). A double-contrast technique involves inflation of the colon using air or carbon dioxide, and peristaltic technique involves inflation of the colon using air or carbon dioxide, and peristaltic activity is temporarily abolished using a short-acting atropine-like pharmacological activity is temporarily abolished using a short-acting atropine-like pharmacological agent.agent.

Colonoscopv provides direct access to lesion- or suspicious areas of mucosa for Colonoscopv provides direct access to lesion- or suspicious areas of mucosa for biopsy: small polypoid lesions may be amenable to removal during the same biopsy: small polypoid lesions may be amenable to removal during the same diagnostic procedure. The examination may not be complete because in a diagnostic procedure. The examination may not be complete because in a significant proportion (10-30%) the caecum is not reached and there are also significant proportion (10-30%) the caecum is not reached and there are also ‘blind’ spots at points of angulation of the colon. Advanced diverticular disease ‘blind’ spots at points of angulation of the colon. Advanced diverticular disease produces deformity and narrowing that is difficult to assess both in barium studies produces deformity and narrowing that is difficult to assess both in barium studies and during colonoscopy.and during colonoscopy.

Colonoscopy has a significantly higher risk of complications than barium enema, Colonoscopy has a significantly higher risk of complications than barium enema, and the procedure is more time consuming.and the procedure is more time consuming.

Table 8 summarises the radiological features of common disorders of the large Table 8 summarises the radiological features of common disorders of the large intestine intestine

Common disorders of the large Common disorders of the large intestine intestine

Carcinoma: Carcinoma: Most are irregular strictures with ‘shouldering’. Destroyed Most are irregular strictures with ‘shouldering’. Destroyed mucosal pattern, proximal dilatation and obstruction. Invasion of adjoining mucosal pattern, proximal dilatation and obstruction. Invasion of adjoining tissues and organs. May appear as polyp, usually more than 2 cm with tissues and organs. May appear as polyp, usually more than 2 cm with complex surface pattern. Long-standing ulcerative colitis and familial complex surface pattern. Long-standing ulcerative colitis and familial polyposis coli are predisposing conditions.polyposis coli are predisposing conditions.

Diverticular disease: Diverticular disease: Multiple diverticula particularly in sigmoid region, Multiple diverticula particularly in sigmoid region, but may be widespread. Narrowing and deformity. Common, so may but may be widespread. Narrowing and deformity. Common, so may coexist with cancer. May bleed or perforate, or form fistulae, e.g. with coexist with cancer. May bleed or perforate, or form fistulae, e.g. with bladder.bladder.

Ulcerative colitis: Ulcerative colitis: Diffuse, uniform fine ulceration; loss of haustra, giving Diffuse, uniform fine ulceration; loss of haustra, giving featureless tubular colon. Toxic megacolon and carcinoma are featureless tubular colon. Toxic megacolon and carcinoma are complications. May only involve distal colon or rectum in some cases.complications. May only involve distal colon or rectum in some cases.

Crohn’s disease: Crohn’s disease: Areas of narrowing, deep ulceration, strictures. Perianal Areas of narrowing, deep ulceration, strictures. Perianal disease is common. Prone to form fistulae. Coexists with small bowel disease is common. Prone to form fistulae. Coexists with small bowel disease often.disease often.

Ischaemic colitis: Ischaemic colitis: Cause of profuse bleeding and acute abdominal pain. Cause of profuse bleeding and acute abdominal pain. Narrowing of lumen, often affecting localised segment, with mucosal Narrowing of lumen, often affecting localised segment, with mucosal oedema (‘thumb-printing’). Occasionally difficult to distinguish from oedema (‘thumb-printing’). Occasionally difficult to distinguish from Crohn’s diseaseCrohn’s disease

Normal oesophagus, (a) Full of barium to show the smooth outline and Normal oesophagus, (a) Full of barium to show the smooth outline and indentation made by the aortic arch (arrow), (b) Film taken after the main indentation made by the aortic arch (arrow), (b) Film taken after the main

volume of barium has passed, to show the parallel mucosal folds.volume of barium has passed, to show the parallel mucosal folds.

Carcinoma of the oesophagus.

The carcinoma is shown as a mass around the lumen of the oesophagus (arrow). Subcarinal nodes (N) are also present. Ao, descending aorta; RPA, right pulmonary artery . There is an irregular stricture with shouldering (arrow) at the upper end.

Peptic stricture due to gastro-oesophageal reflux in a patient with a hiatus Peptic stricture due to gastro-oesophageal reflux in a patient with a hiatus hernia. There is a short smooth stricture at the oesophagogastric junction with hernia. There is a short smooth stricture at the oesophagogastric junction with

an ulcer crater within the stricture (arrow).an ulcer crater within the stricture (arrow).

Achalasia. The very dilated oesophagus containing food residues Achalasia. The very dilated oesophagus containing food residues shows a smooth narrowing at its lower end.shows a smooth narrowing at its lower end.

Leiomyoma

. There is a large filling defect in the stomach with smooth borders (outer arrows). An ulcer crater (central arrow) is present within the filling defect - a characteristic feature of a leiomyoma

There is an intramural filling defect in the eosophagus below the aortic arch (arrows). The sharp angle this makes with the wall of the oesophagus indicates that the filling defect is due to a mass arising in the wall of the oesophagus

Oesophageal varices. Tortuous, Oesophageal varices. Tortuous, worm-like filling defects are seen worm-like filling defects are seen

in the lower half of the in the lower half of the oesophagus.oesophagus.

Pharyngeal pouch (Zenker's Pharyngeal pouch (Zenker's diverticulum). The pouch is diverticulum). The pouch is lying behind the oesophagus lying behind the oesophagus which is displaced forwardwhich is displaced forward..

Duodenal diverticulum arising from the second part of the duodenum (arrows)

Normal stomach and duodenum: double-contrast barium meal. On this supine Normal stomach and duodenum: double-contrast barium meal. On this supine view barium collects in the fundus of the stomach. The body and the antrum view barium collects in the fundus of the stomach. The body and the antrum

of the stomach together with the duodenal cap and loop are coated with of the stomach together with the duodenal cap and loop are coated with barium and distended with gas. Note how the fourth part of the duodenum and barium and distended with gas. Note how the fourth part of the duodenum and

duodenojejunal flexure are superimposed on the body of duodenojejunal flexure are superimposed on the body of the the stomachstomach

Carcinoma. There are a number of large filling defects in the antrum and body Carcinoma. There are a number of large filling defects in the antrum and body of the stomachof the stomach

Benign ulcer, (a) In profile the ulcer (arrow) projects from the lesser curve of Benign ulcer, (a) In profile the ulcer (arrow) projects from the lesser curve of the stomach, (b) the stomach, (b) En face En face the ulcer (arrow) is seen as a rounded collection of the ulcer (arrow) is seen as a rounded collection of

barium.barium.

Malignant ulcer. The ulcer (arrow) does not project from the lumen of the Malignant ulcer. The ulcer (arrow) does not project from the lumen of the stomach. Note how the mucosal folds do not reach the ulcer crater. The stomach. Note how the mucosal folds do not reach the ulcer crater. The

stomach is narrowed by an extensive carcinoma converting it to a rigid tube stomach is narrowed by an extensive carcinoma converting it to a rigid tube with obliteration of mucosal folds.with obliteration of mucosal folds.

Gastric outlet obstruction. A carcinoma is causing narrowing of the antrum Gastric outlet obstruction. A carcinoma is causing narrowing of the antrum (arrow). The speckled appearance in the fundus of the enlarged stomach is due (arrow). The speckled appearance in the fundus of the enlarged stomach is due

to food residuesto food residues

Erosive gastritis. The erosions appear on this double-contrast barium meal as Erosive gastritis. The erosions appear on this double-contrast barium meal as many small collections of barium, some of which are arrowed, surrounded by many small collections of barium, some of which are arrowed, surrounded by

a radiolucent halo of oedema.a radiolucent halo of oedema.

Hiatus hernia, Sliding: the fundus of the stomach and the gastro-oesophageal Hiatus hernia, Sliding: the fundus of the stomach and the gastro-oesophageal junction (arrow) have herniated through the oesophageal hiatus and lie above junction (arrow) have herniated through the oesophageal hiatus and lie above

the diaphragm (dotted line)the diaphragm (dotted line)

((a) Normal barium follow-through. The small intestine, ascending and transverse a) Normal barium follow-through. The small intestine, ascending and transverse colon are filled with barium. The jejunum in the left side of the abdomen has a colon are filled with barium. The jejunum in the left side of the abdomen has a much more marked mucosal fold pattern than the ileum which is lying in the much more marked mucosal fold pattern than the ileum which is lying in the

pelvis. When a peristaltic wave contracts the bowel the mucosal folds lie pelvis. When a peristaltic wave contracts the bowel the mucosal folds lie longitudinally (arrows). Note the way of measuring the diameter of the bowel. In longitudinally (arrows). Note the way of measuring the diameter of the bowel. In the pelvis the pelvis the the loops overlap and details of the bowel become hidden, (b) Normal loops overlap and details of the bowel become hidden, (b) Normal

terminal ileumterminal ileum

Normal small bowel enema. This Normal small bowel enema. This technique gives good mucosal detail. technique gives good mucosal detail.

The arrow points to the terminal The arrow points to the terminal ileum. Note that a tube has been ileum. Note that a tube has been

passed through the stomach into the passed through the stomach into the jejunumjejunum

Dilatation from small bowel obstruction. The diameter of the bowel is greatly increased. The feathery mucosal pattern is lost and the folds appear as thin lines traversing the bowel, known as valvulae conniventes (arrows).

Mucosal abnormality with infiltration Mucosal abnormality with infiltration of the bowel, in this case from of the bowel, in this case from

oedema. The mucosal folds become oedema. The mucosal folds become thickened. Some of the thickened thickened. Some of the thickened

folds are arrowedfolds are arrowed

Narrowing. There is a long irregular stricture (arrows) in the terminal ileum due to Crohn's disease. There is an abnormal mucosal pattern in the remainder of the terminal ileum. Note the contracted caecum - another feature of the disease

Ulceration. Abnormal loops of bowel in Crohn's disease showing the ulcers as outward projections (arrows).

Displacement. The small bowel is Displacement. The small bowel is displaced around enlarged displaced around enlarged

abdominal lymph nodes from a abdominal lymph nodes from a metastatic teratoma of the testis.metastatic teratoma of the testis.

Malrotation. The small bowel is situated in the right side of the

abdomen. Later films showed the colon on the left side.Crohn's disease

Diverticulosis. A number of diverticula of varying size are arising from the Diverticulosis. A number of diverticula of varying size are arising from the small bowel. Some of these are arrowed multiple small bowel diverticula a small bowel. Some of these are arrowed multiple small bowel diverticula a

dilated loop cut off from the main stream of the bowel in which there is dilated loop cut off from the main stream of the bowel in which there is delayed filling and emptying (blind loop)delayed filling and emptying (blind loop)

Stricture. A short circumferential narrowing is seen in the sigmoid colon Stricture. A short circumferential narrowing is seen in the sigmoid colon (arrow) from a carcinoma.(arrow) from a carcinoma.

Extrinsic compression. A narrowed Extrinsic compression. A narrowed length of sigmoid colon is seen length of sigmoid colon is seen caused by compression by an caused by compression by an

adjacent ovarianadjacent ovarian

Extrinsic compression. An appendix abscess is compressing and narrowing the caecum.

Filling defects. Lumps of faeces have caused Filling defects. Lumps of faeces have caused smooth filling defects surrounded by barium. smooth filling defects surrounded by barium. However, in the sigmoid colon there is a large However, in the sigmoid colon there is a large

filling defect with ill-defined edges (arrow). This filling defect with ill-defined edges (arrow). This is a carcinoma. A clean colon is essential for a is a carcinoma. A clean colon is essential for a

satisfactory barium enema.satisfactory barium enema.

Muscle hypertrophy and diverticula. Muscle hypertrophy gives the sigmoid colon a serrated appearance. Two small diverticula are arrowed

Ulceration, (a) Single contrast. (b) Double contrast. In this case of ulcerative Ulceration, (a) Single contrast. (b) Double contrast. In this case of ulcerative colitis the ulceration causes the normally smooth outline of the colon to be colitis the ulceration causes the normally smooth outline of the colon to be

irregular.irregular.

Ulcerative colitis. With long-standing disease the haustra are lost and the Ulcerative colitis. With long-standing disease the haustra are lost and the colon becomes narrowed and shortened coming to resemble a rigid tube. colon becomes narrowed and shortened coming to resemble a rigid tube.

Reflux into the ileum through an incompetent ileocaecal valve has occurred.Reflux into the ileum through an incompetent ileocaecal valve has occurred.

A). Crohn's disease. The mucosal pattern has a 'cobblestone' appearance due to A). Crohn's disease. The mucosal pattern has a 'cobblestone' appearance due to criss-crossing fine ulceration. B). Crohn's disease - strictures. A long stricture is criss-crossing fine ulceration. B). Crohn's disease - strictures. A long stricture is present in the transverse colon (between curved arrows) and a shorter one in the present in the transverse colon (between curved arrows) and a shorter one in the

sigmoid colon (between small arrows). In this case the outline of the strictures are sigmoid colon (between small arrows). In this case the outline of the strictures are irregular, due to ulceration. C). These two abnormal segments with normal irregular, due to ulceration. C). These two abnormal segments with normal

intervening bowel are an example of skip lesions' - an important diagnostic feature intervening bowel are an example of skip lesions' - an important diagnostic feature of Crohn'sof Crohn's

a

b c

Diverticular disease. Numerous Diverticular disease. Numerous diverticula are seen as out-pouchings diverticula are seen as out-pouchings

from the sigmoid colonfrom the sigmoid colon

Diverticular disease. A stricture is present (arrow). Although there is recognizable diverticular disease at both ends of the stricture, it is impossible to exclude definitely a carcinoma

Polyps within the colon may be demonstrated as radiolucent filling defects Polyps within the colon may be demonstrated as radiolucent filling defects displacing the contrast substance. Note stalk, which is well seen.displacing the contrast substance. Note stalk, which is well seen.