BEKTI SAFARINI FAKULTAS KEDOKTERAN UNISSULA SEMARANG IMAGING THE ABDOMEN Plain Film Contras studies CT MRI Ultrasound Nuclear Scintigraphy FPA A number of indications for requesting abdominal films: Bowel obstruction - abnormal gas pattern Free air - abnormal gas pattern Abscess - abnormal gas pattern Calculi or other abnormal intra-abdominal calcifications Radiopaque foreign bodies FPA : Apa saja yang dinilai? Preperitoneal fat line Psoas line Pola udara dalam saluran cerna Adanya udara bebas Soft tissue mass(+)/(-) Kalsifikasi (+) / (-) Tulang POLA NORMAL UDARA DALAM SALURAN PENCERNAAN Lambung : Udara selalu (+) Usus kecil : terlihat 2-3 loop usus, tak ada distensi.Diameter < 3cm Rectum dan Sigmoid : selalu terlihat Udara dalam lambung Udara terlihat pada bbrpa loop usus halus Udara dalam Rectum & Sigmoid NORMAL FLUID LEVEL Lambung : selalu (+), kecuali proyeksi supine Usus kecil: 2-3 fluid level masih normal Usus besar : 2-5 fluid level masih normal Air fluid level di lambung Air fluid level sedikit pada usus kecil USUS BESAR VS USUS KECIL Usus Besar Perifer Haustra: plika semi lunaris Diameter < 6 cm, cecum <9 cm Usus Kecil Central Valvulae: plika sirkularis Diameternya < 3 cm PROYEKSI FPA Supine (paling sering) Prone Left Lateral Dicubitus(LLD) Erect atau semi erect Pada kasus obstruktivus biasanya digunakan proyeksi > 1 atau cukup 1 proyeksi erect dengan sinar horisontal FPA SUPINE Untuk melihat : • Pola udara dalam usus • Kalsifikasi • Soft tissue mass • Tulang FPA PRONE Untuk melihat : • Udara dalam rectum/ sigmoid • Udara dalam colon asenden dan desenden FPA ERECT Untuk melihat : • Free-air • Air fluid level Dapat digantikan dengan Proyeksi Left Lateral Decubitus(LLD) PNEUMOPERITONEUM PNEUMOPERITONEUM Udara bebas intraperitoneum atau ekstraluminer Causa : - Robeknya dinding saluran cerna (trauma, iatrogenik, kelainan di saluran cerna), - Tidakan melalui permukaan peritoneal (transperitoneal manipulasi, endoscopic biopsy, abdominal needle biopsy) - Intraperitoneal ( gas forming peritonitis, ruptur abses ) PNEUMOPERITONEUM Gambaran Radiologi : Cupula sign Foot ball sign Double wall sign /Rigler sign Ligamentum falciforum sign Umbilical sign Urachus sign PROYEKSI FOTO Biasanya menggunakan 2 proyeksi foto : - FPA supine - X Thorak erect atau left lateral decubitus Cupula sign Cupula sign Air on both sides of bowel wall – Rigler’s Sign Free Intraperitoneal Air Umbilical sign Urachus sign Falciform Ligament Sign Football sign Free Intraperitoneal Air ABNORMALITAS POLA UDARA DALAM USUS ABNORMALITAS POLA UDARA Fungsional Ileus : Localized (sentinel loop) Generalized adynamic ileus Mechanical Obstructions : Small bowel obstructions(SBO) Large bowel obstructions (LBO) Air in Rectum/ Sigmoid Air in small bowel Air in large bowel Localized Ileus + 2-3 distended loops Air in rectum/ sigmoid Generalized Ileus + Multiple distended loop Distended SBO - Multiple dilated loop - LBO - None-unless Ileocecal valve incompetent Dilated LOCALIZED ILEUS ( Sentinel Loop ) 1 atau 2 loop usus kecil atau usus besar yang dilatasi persisten Udara dalam rectum / sigmoid (+) Prone Supine Cholecystitis Appendicitis Pancreatitis Ulcer Diverticulitis Ulcer Ureteral calculus Sentinel Loops GENERALIZED ILEUS Gambaran udara dalam usus kecil dan usus besar yang dilatasi Udara dalam rectum/ sigmoid (+) Multipel air fluid level panjang Sering terjadi pada pasien post operasi Erect Supine Generalized Adynamic Ileus SMALL BOWEL OBSTRUCTIONS Dilatasi usus kecil Gambaran coil spring dan herring bone Udara dalam colon minimal, terutama di daerah rectum Multipel air fluid level pendek Causa : Adhesi, volvulus, gallstone ileus. intusupsesi SBO Coil spring LARGE BOWEL OBSTRUCTIONS Dilatasi colon Udara minimal terutama di rectum Udara di usus kecil minimal/ (-) jika katub ileocecal competent Jika katub ileocecal incompetent maka akan terjadi decompresi udara dari colon ke usus kecil Causa : tumor, volvulus, hernia divertikulitis, intususepsi Supine Prone Supine Prone "Normal" calcifications Bones are the only normal calcified structures. Many other calcifications will be seen that have no clinical significance Vascular-veins of the pelvis (phleboliths) Costal cartilage Lymph nodes Granulomas Injection sites ABNORMAL CALCIFICATIONS URETEROLITHIASIS UTERINE FIBROID APPENDICOLITH CONTRAST STUDY UPPER GI TRACT PEMERIKSAAN UPPER GI TRACT Pemeriksaan radiologi pada esofagus, lambung & duodenum (batas distal : ligamentum Treitz). Dapat memeriksa fungsi, struktur dan pergerakan organ. Dapat memeriksa lapisan dalam dan luar organ. Menggunakan kontras barium (terbanyak) Curiga perforasi kontras yang larut dalam air. Pengetahuan teknik radiologis dx. & pengenalan gambaran PEMERIKSAAN UPPER GI TRACT Barium Swallow Generally both single contrast & air contrast is performed. Using flurouscopy & allow for the assesment os. Motilithy, contour, obstructions & abnormalitilies of the lumen. BARIUM SWALLOW AIR CONTRAST AP LAT BARIUM SWALLOW SINGLE CONTRAST BARIUM SWALLOW DOUBLE CONTRAST ABNORMAL CONTOUR ABNORMAL MOTILITY AKALASIA Plain film dilated and tortuous esophagus, with amounts of retained food and fluid aspiration of material leads to chronic interstitial pulmonary disease stomach bubble is small or absent Esophagram weak nonpropulsive peristaltic waves below level of cricopharyngeus will persist even after LES has been fixed incomplete emptying of esophagus even in upright position "rat tail" or "beak" appearance--gradual smooth tapering of distal esophagus extends for 1 to 3 cm Hurst Phenomenon--temporary transit through cardia provoked by hydrostatic pressure of barium column reaching above a critical level AKALASIA VARISES ESOFAGUS ESOFAGITIS PEPTIK KARCINOMA ESOFAGUS DIVERTIKEL ESOFAGUS ESOFAGUS BARRETT BARIUM FOLLOW THROUGH BARIUM ENEMA COLON IN LOOP - Single contrast - Double contrast CA COLON Double-contrast barium enema showing an “apple core” lesion involving the sigmoid colon CT COLONOGRAPHY VIRTUAL CT-COLONOGRAPHY ORGAN VISERA ORGANS • • • • • • • Liver Gallbladder Pancreas Spleen Stomach Small intestine Large Intestine Organ plain radiograph hard to see AXIAL IMAGING • CT • MRI • ULTRASOUND COMPUTED TOMOGRAPHY Contras ? • Oral - Dilute iodine - Dilute barium • Intravenous - Iodine ( Non-ionic ) LIVER CT LIVER MRI LIVER ULTRASOUND GALBLADDER CT GALBLADDER US MR CHOLANGIOPANCREATOGRAM (MRCP) A cruise Through the Abdomen on a CT Scan • In the past, patients with abdominal problem would first a plain radiograph. • Then perhaps an upper GI series ( UGI ) and / or barium enema ( BE ) • Today, it is very common to obtain a CT - Shown more anatomic detail than X-Rays. - Much of the same informations as UGI