Pathology & Imaging

• Most plain abdomen radiographs are inappropriate in acute situations
• Plain abdominal radiographs


  • Accessibility
  • Cost effective
  • Speed
  • Minimal Patient discomfort
  • Useful for screening

  
• Plain abdominal radiographs


  • Limited sensitivity
  • Low contrast resolution
  • Ionising radiation
  • Inadequate for detailed evaluation
  • Overlapping structures
  • Limited information

  
• Bowel/Intestinal obstruction


  • Clinical presentation: Vomiting and Nausea
  • Abdominal pain
  • Abdominal distension
  • Absolute constipation
  • Loud bowel sound
  • Dehydration
• Causes of bowel/intestinal obstruction

  • Small bowel- adhesions, hernia, malignancies
  • Large bowel- Cancer, volvulus (twist), diverticular disease
• Volvulus


  Occurs when the bowel twist around its mesentery. Types: Gastric, Midgut, Caecal and Sigmoid
• Volvulus appearance


  • 'coffee bean sign'- Sigmoid
  • 'kidney bean sign'- Caecal
• Barium studies


  • Barium sulfate (radio opaque)
  • Used when suspected perforation, post op leak, trachea-oesophageal fistula
• Excessive exposure of ionizing radiation to both, the radiologist and the patient
• Over the last 30 years the advent of ultrasonography, endoscopy, capsule endoscopy, physiological monitoring, and axial imaging (CT and MRI) relegated the superiority of barium examinations
• Advantages of barium studies

  • Speech therapy assessment, mechanics of swallowing
  • Assessment of motility disorders
  • Inexpensive
  • Non-invasive (compared to endoscopy)
  • Wide availability
  • Can be modified for patients (thicker product when swallowing)
• Barium swallow


  Dedicated examination of the pharynx, oesophagus and proximal stomach
• Barium meal


  To examine the oesophagus, stomach and duodenum
• Barium follow through


  To study the small intestine
• Barium enema


  To visualise the large intestine
• Diverticular disease


  • Small pouches form through weakened areas in the large intestine (mostly within sigmoid colon)
  • When there are no symptoms: diverticulosis
  • With symptoms: diverticular disease
  • Inflamed or infected diverticula: diverticulitis
• Contributing factors for diverticular disease

  • Age
  • Obesity
  • Smoking
  • Diet high in animal fat and low in fibre
• Diverticular disease clinical indications

  • Abdominal pain (usually left lower side and worse after eating)
  • Constipation
  • Diarrhoea
  • Blood in faeces
  • Mucus in faeces
  • High temperature (if infected)
• Diverticular disease treatment


  • High fibre diet
  • Antibiotics
  • Surgery- colectomy
• After barium studies, the barium may take several days to pass through the system. Patients should drink plenty of fluids and eat high fibre foods to help it pass more quickly.
• Steps to deliver person centred care during Barium studies

  GROUPWORK
• CT for bowel perforation

  • CT is the primary imaging modality for detection and localisation of bowel perforation
  • CT is accurate in detecting the site of perforation in 85% of the cases

  
• Increasingly more CT scans are being undertaken (0.47 million CT scans in 2018-19)
• CT abdomen


  • Typically from diaphragm to symphysis pubis
  • IV contrast media can be used
• CT abdomen


  • Relatively quick and accessible
  • Reproducible findings
  • Complete assessment of the abdomen and pelvis
• CT abdomen


  • Uses ionising radiation
  • Approximately 100 times the dose of a chest radiograph
  • Requires iodinated IV contrast
  • Risk of renal impairment
  • Risk of anaphylactic reaction
• CT colonography


  • Patients are adequately prepared with bowel preparation
  • Bowel distension using carbon dioxide
  • IV contrast can also be used assess other abdominal organs
  • Buscopan can also be given- reduces bowel spasms and discomfort
• Bowel perforation


  • Intestinal perforation, defined as a loss of continuity of the bowel wall, is a potentially devastating complication that may result from a variety of disease processes
  • Common causes: Trauma, Instrumentation, Inflammation, Infection, Malignancy
• Pathology


  • Bowel obstruction
  • Bowel perforation
  • Colon cancer
  • Intra-abdominal trauma
• Advantages of CT


  • Relatively quick and accessible
  • Reproducible findings
  • Complete assessment of the abdomen and pelvis
• Disadvantages of CT


  • Uses ionising radiation
  • Approximately 100 times the dose of a chest radiograph
  • Requires iodinated IV contrast
  • Risk of renal impairment
  • Risk of anaphylactic reaction
• CT Colonography


  1. Patients are adequately prepared with bowel preparation

  2. Bowel distension using carbon dioxide

  3. IV contrast can also be used assess other abdominal organs

  4. Buscopan can also be given- reduces bowel spasms and discomfort
• Bowel perforation


  Intestinal perforation, defined as a loss of continuity of the bowel wall, is a potentially devastating complication that may result from a variety of disease processes
• Common causes of bowel perforation

  • Trauma
  • Instrumentation
  • Inflammation
  • Infection
  • Malignancy
  • Ischemia
  • Obstruction
• Bowel perforation patient presentation

  • Severe stomach pain
  • Rigid abdomen
  • Chills
  • Fever
  • Nausea
  • Vomiting
• CT Imaging of bowel perforation

  1. Tracking pneumoperitoneum toward a region of bowel

  2. Localised peritoneal fat stranding, bowel wall thickening, or abnormal bowel wall enhancement

  3. Bowel wall discontinuity

  4. Oral contrast leak (if administrated) – water soluble contrast!

  5. If a bowel perforation occurs due to obstruction, the perforation usually occurs at the site of maximal bowel distention and the perforation may be distant from the actual cause of the bowel obstruction

  6. Liquid contents exiting the bowel may form an abscess
• CT Colonography


  • Screening for Ca
  • Colon evaluation after unsuccessful colonoscopy
  • Patients contraindicated / declined colonoscopy
• Pathology detected by CT Colonography

  • Diverticulitis
  • Polyps
  • Ca
• Advantages of CT Colonography

  • Relatively quick and accessible
  • Less invasive
  • Can visualise colon beyond an obstruction
• Disadvantages of CT Colonography

  • Uses ionising radiation
  • Risk of radiation-induced cancer
  • Approximately 100 times the dose of a chest radiograph
  • IBD contraindicated (increased risk of perforation)
  • Recent surgery contraindicated