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Gastrointestinal Imaging

E3258. Throwback Thursday: The Art of Fluoroscopy

Chowdhary V,  Koshy J. Staten Island University Hospital, Northwell Health, Staten Island, NY

Address correspondence to V. Chowdhary (varunchowdhary1@gmail.com)

Background Information: Fluoroscopy is increasingly being replaced by modern technology. However, it is still a key component of several aspects of radiology. Many radiology residents are not always comfortable with interpreting fluoroscopy. In this exhibit, descriptions of several disease processes and their fluoroscopic correlates are described.

Educational Goals/Teaching Points: We present different types of fluoroscopic studies and relevant anatomy. We include fluoroscopic diagnoses based on location including esophagus, stomach, duodenum, small bowel, and colon. We offer pearls and pitfalls of fluoroscopy.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques: Fluoroscopy is the real-time evaluation of moving parts within the body. Although the diagnosis of many diseases is performed with CT or endoscopies, it is important to understand their fluoroscopic correlates. In this exhibit, various diseases are divided into esophagus, stomach, duodenum, small bowel, and colon. In all these sections, diseases can be subdivided into inflammatory and ulcerative, strictures, masses and filling defects, and diverticula. For example, with a double-contrast (air and oral barium) esophagram, if thickened and nodular folds are seen distally then the diagnosis is likely to be reflux esophagitis. However, it is important to understand the entire clinical scenario because esophageal varices can have a very similar appearance. However, there are certain diagnoses that are more specific on fluoroscopy; for example, if multiple tiny outpouchings are seen within the mid esophagus around a stricture, then the diagnosis can only be intramural esophageal pseudodiverticulosis. In the stomach, if multiple erosions are present in the gastric antrum then the differential diagnosis include erosive gastritis and Crohn disease. To differentiate the two entities further evaluation of the small bowel and colon should be performed. In the duodenum, if the proximal duodenum is dilated to the level of the spine and abruptly narrows then the differential includes superior mesenteric artery (SMA) syndrome, duodenal neoplasm, or abdominal aortic aneurysm. During fluoroscopy, SMA syndrome can be differentiated by laying the patient prone and evaluating if oral contrast passes more easily. In the small bowel, a rare entity such as Ascariasis has a very specific appearance on small bowel follow-through: elongated filling defect with thin white line traversing the length of the filling defect. In the colon, if multiple wide-mouth sacculations are present along the anti-mesenteric border of the transverse colon then the differential diagnosis includes scleroderma or Crohn disease. Once again, the clinical history will be revealing but other findings such as intervening normal colon can be used to differentiate Crohn disease. Many other disease processes are discussed while focusing on a systematic approach.

Conclusion: Fluoroscopy is an important entity to diagnose several diseases. In fact, several entities have very specific fluoroscopic findings such that further evaluation with cross-sectional imaging is not needed. Therefore, it is important for trainees to understand the value of fluoroscopy.