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Gastrointestinal Radiology in the United States: An Overview of the Past 50 Years¹

¹ From the Department of Radiology, University of California San Francisco, San Francisco, CA 94143-0628. Received October 29, 1999; revision requested December 7; revision received January 14, 2000; accepted January 27. Address correspondence to H.I.G. (e-mail: henry.goldberg@radiology.ucsf.edu).

View larger version (110K): [in a new window]   Figure 1a. (a) Cholecystogram obtained after oral administration of contrast material demonstrates excellent opacification of the gallbladder without evidence of stones. (b) US image obtained 1 day after a illustrates the increased sensitivity of US for detection of stones (curved arrow) in the presence of an otherwise normal-appearing gallbladder (straight arrow). The cholecystogram has become a "museum piece" in the United States as the result of US. This may be related more to the convenience of obtaining US images of the gallbladder, particularly in the acutely ill patient, than to its overall superiority for help in detecting stones.

View larger version (154K): [in a new window]   Figure 1b. (a) Cholecystogram obtained after oral administration of contrast material demonstrates excellent opacification of the gallbladder without evidence of stones. (b) US image obtained 1 day after a illustrates the increased sensitivity of US for detection of stones (curved arrow) in the presence of an otherwise normal-appearing gallbladder (straight arrow). The cholecystogram has become a "museum piece" in the United States as the result of US. This may be related more to the convenience of obtaining US images of the gallbladder, particularly in the acutely ill patient, than to its overall superiority for help in detecting stones.

View larger version (152K): [in a new window]   Figure 2a. The addition of newer techniques for detection and characterization of small-bowel obstruction has affected the treatment of patients during the past 50 years. The following images represent five patients. (a) Radiograph of the abdomen obtained in a patient in the supine position shows extensively dilated small bowel with no colonic air. This image represents the primary study of small-bowel obstruction. Conventional radiography has persisted over the past 50 years. (b) Small-bowel barium study obtained with a transit time of 3 hours is an ideal depiction of obstruction (arrow). Barium study was the only other technique available in the 1950s and 1960s to help analyze obstruction. (c) Radiograph obtained at enteroclysis, which was introduced in the late 1970s, provides additional options for help in the detection and characterization of small-bowel obstruction, which is shown here as an abrupt termination (arrow) of the barium column. The cause of obstruction in this patient was tumor implants (metastases) on the bowel from recurrent ovarian cancer. The results were obtained 20 minutes after intubation. (d) The use of CT scans, introduced in the 1980s, to evaluate suspected small-bowel obstruction extended the ability of radiologists to characterize the cause of obstruction. This transverse CT scan demonstrates multiple segments of small-bowel dilatation caused by an incarcerated bowel loop (arrow) in an anterior abdominal wall hernia. (e) The newest technique to be applied to evaluation of the small bowel is MR imaging. By using water as a contrast agent and a coronal T2-weighted single-shot fast spin-echo technique (repetition time = , echo time = 280 msec, 40-mm section thickness), the bowel lumen, fold pattern, and relationship of one segment to another can be shown. It is yet to be determined where MR imaging will fit in the algorithms for imaging of small-bowel obstruction. (Reprinted, with permission, from reference 44.)

View larger version (140K): [in a new window]   Figure 2b. The addition of newer techniques for detection and characterization of small-bowel obstruction has affected the treatment of patients during the past 50 years. The following images represent five patients. (a) Radiograph of the abdomen obtained in a patient in the supine position shows extensively dilated small bowel with no colonic air. This image represents the primary study of small-bowel obstruction. Conventional radiography has persisted over the past 50 years. (b) Small-bowel barium study obtained with a transit time of 3 hours is an ideal depiction of obstruction (arrow). Barium study was the only other technique available in the 1950s and 1960s to help analyze obstruction. (c) Radiograph obtained at enteroclysis, which was introduced in the late 1970s, provides additional options for help in the detection and characterization of small-bowel obstruction, which is shown here as an abrupt termination (arrow) of the barium column. The cause of obstruction in this patient was tumor implants (metastases) on the bowel from recurrent ovarian cancer. The results were obtained 20 minutes after intubation. (d) The use of CT scans, introduced in the 1980s, to evaluate suspected small-bowel obstruction extended the ability of radiologists to characterize the cause of obstruction. This transverse CT scan demonstrates multiple segments of small-bowel dilatation caused by an incarcerated bowel loop (arrow) in an anterior abdominal wall hernia. (e) The newest technique to be applied to evaluation of the small bowel is MR imaging. By using water as a contrast agent and a coronal T2-weighted single-shot fast spin-echo technique (repetition time = , echo time = 280 msec, 40-mm section thickness), the bowel lumen, fold pattern, and relationship of one segment to another can be shown. It is yet to be determined where MR imaging will fit in the algorithms for imaging of small-bowel obstruction. (Reprinted, with permission, from reference 44.)

View larger version (131K): [in a new window]   Figure 2c. The addition of newer techniques for detection and characterization of small-bowel obstruction has affected the treatment of patients during the past 50 years. The following images represent five patients. (a) Radiograph of the abdomen obtained in a patient in the supine position shows extensively dilated small bowel with no colonic air. This image represents the primary study of small-bowel obstruction. Conventional radiography has persisted over the past 50 years. (b) Small-bowel barium study obtained with a transit time of 3 hours is an ideal depiction of obstruction (arrow). Barium study was the only other technique available in the 1950s and 1960s to help analyze obstruction. (c) Radiograph obtained at enteroclysis, which was introduced in the late 1970s, provides additional options for help in the detection and characterization of small-bowel obstruction, which is shown here as an abrupt termination (arrow) of the barium column. The cause of obstruction in this patient was tumor implants (metastases) on the bowel from recurrent ovarian cancer. The results were obtained 20 minutes after intubation. (d) The use of CT scans, introduced in the 1980s, to evaluate suspected small-bowel obstruction extended the ability of radiologists to characterize the cause of obstruction. This transverse CT scan demonstrates multiple segments of small-bowel dilatation caused by an incarcerated bowel loop (arrow) in an anterior abdominal wall hernia. (e) The newest technique to be applied to evaluation of the small bowel is MR imaging. By using water as a contrast agent and a coronal T2-weighted single-shot fast spin-echo technique (repetition time = , echo time = 280 msec, 40-mm section thickness), the bowel lumen, fold pattern, and relationship of one segment to another can be shown. It is yet to be determined where MR imaging will fit in the algorithms for imaging of small-bowel obstruction. (Reprinted, with permission, from reference 44.)

View larger version (145K): [in a new window]   Figure 2d. The addition of newer techniques for detection and characterization of small-bowel obstruction has affected the treatment of patients during the past 50 years. The following images represent five patients. (a) Radiograph of the abdomen obtained in a patient in the supine position shows extensively dilated small bowel with no colonic air. This image represents the primary study of small-bowel obstruction. Conventional radiography has persisted over the past 50 years. (b) Small-bowel barium study obtained with a transit time of 3 hours is an ideal depiction of obstruction (arrow). Barium study was the only other technique available in the 1950s and 1960s to help analyze obstruction. (c) Radiograph obtained at enteroclysis, which was introduced in the late 1970s, provides additional options for help in the detection and characterization of small-bowel obstruction, which is shown here as an abrupt termination (arrow) of the barium column. The cause of obstruction in this patient was tumor implants (metastases) on the bowel from recurrent ovarian cancer. The results were obtained 20 minutes after intubation. (d) The use of CT scans, introduced in the 1980s, to evaluate suspected small-bowel obstruction extended the ability of radiologists to characterize the cause of obstruction. This transverse CT scan demonstrates multiple segments of small-bowel dilatation caused by an incarcerated bowel loop (arrow) in an anterior abdominal wall hernia. (e) The newest technique to be applied to evaluation of the small bowel is MR imaging. By using water as a contrast agent and a coronal T2-weighted single-shot fast spin-echo technique (repetition time = , echo time = 280 msec, 40-mm section thickness), the bowel lumen, fold pattern, and relationship of one segment to another can be shown. It is yet to be determined where MR imaging will fit in the algorithms for imaging of small-bowel obstruction. (Reprinted, with permission, from reference 44.)

View larger version (133K): [in a new window]   Figure 2e. The addition of newer techniques for detection and characterization of small-bowel obstruction has affected the treatment of patients during the past 50 years. The following images represent five patients. (a) Radiograph of the abdomen obtained in a patient in the supine position shows extensively dilated small bowel with no colonic air. This image represents the primary study of small-bowel obstruction. Conventional radiography has persisted over the past 50 years. (b) Small-bowel barium study obtained with a transit time of 3 hours is an ideal depiction of obstruction (arrow). Barium study was the only other technique available in the 1950s and 1960s to help analyze obstruction. (c) Radiograph obtained at enteroclysis, which was introduced in the late 1970s, provides additional options for help in the detection and characterization of small-bowel obstruction, which is shown here as an abrupt termination (arrow) of the barium column. The cause of obstruction in this patient was tumor implants (metastases) on the bowel from recurrent ovarian cancer. The results were obtained 20 minutes after intubation. (d) The use of CT scans, introduced in the 1980s, to evaluate suspected small-bowel obstruction extended the ability of radiologists to characterize the cause of obstruction. This transverse CT scan demonstrates multiple segments of small-bowel dilatation caused by an incarcerated bowel loop (arrow) in an anterior abdominal wall hernia. (e) The newest technique to be applied to evaluation of the small bowel is MR imaging. By using water as a contrast agent and a coronal T2-weighted single-shot fast spin-echo technique (repetition time = , echo time = 280 msec, 40-mm section thickness), the bowel lumen, fold pattern, and relationship of one segment to another can be shown. It is yet to be determined where MR imaging will fit in the algorithms for imaging of small-bowel obstruction. (Reprinted, with permission, from reference 44.)

View larger version (129K): [in a new window]   Figure 3a. The application of CT for help in detection and characterization of hepatic lesions has revolutionized the management of hepatic malignancies by permitting directed surgical resection, directed infusion chemotherapy, and chemical ablation of tumors. (a) Transverse CT scan of the liver (acquisition time, 18 seconds) obtained in 1976 without use of intravenous contrast material. No hepatic lesion is depicted despite the proved presence of a 4-cm-diameter hepatocellular carcinoma lesion. (b) Transverse CT scan in a different patient was obtained in 1999 by using helical CT technology and a triple-phase contrast enhancement protocol. This portal venous phase image demonstrates a lesion (arrow) posteriorly distributed in the right lobe. The lesion has both hypo- and hypervascular components. (c) Transverse arterial phase CT scan in the same patient as in b demonstrates not only the dominant right lobe lesion but also multiple small hypervascular lesions (arrows) in the anterior portion of the right lobe and throughout all segments of the left lobe. This information aids the surgeon in designating this cancer as inoperable. If the portal venous phase image alone had been obtained, a different decision might have been made.

View larger version (129K): [in a new window]   Figure 3b. The application of CT for help in detection and characterization of hepatic lesions has revolutionized the management of hepatic malignancies by permitting directed surgical resection, directed infusion chemotherapy, and chemical ablation of tumors. (a) Transverse CT scan of the liver (acquisition time, 18 seconds) obtained in 1976 without use of intravenous contrast material. No hepatic lesion is depicted despite the proved presence of a 4-cm-diameter hepatocellular carcinoma lesion. (b) Transverse CT scan in a different patient was obtained in 1999 by using helical CT technology and a triple-phase contrast enhancement protocol. This portal venous phase image demonstrates a lesion (arrow) posteriorly distributed in the right lobe. The lesion has both hypo- and hypervascular components. (c) Transverse arterial phase CT scan in the same patient as in b demonstrates not only the dominant right lobe lesion but also multiple small hypervascular lesions (arrows) in the anterior portion of the right lobe and throughout all segments of the left lobe. This information aids the surgeon in designating this cancer as inoperable. If the portal venous phase image alone had been obtained, a different decision might have been made.

View larger version (125K): [in a new window]   Figure 3c. The application of CT for help in detection and characterization of hepatic lesions has revolutionized the management of hepatic malignancies by permitting directed surgical resection, directed infusion chemotherapy, and chemical ablation of tumors. (a) Transverse CT scan of the liver (acquisition time, 18 seconds) obtained in 1976 without use of intravenous contrast material. No hepatic lesion is depicted despite the proved presence of a 4-cm-diameter hepatocellular carcinoma lesion. (b) Transverse CT scan in a different patient was obtained in 1999 by using helical CT technology and a triple-phase contrast enhancement protocol. This portal venous phase image demonstrates a lesion (arrow) posteriorly distributed in the right lobe. The lesion has both hypo- and hypervascular components. (c) Transverse arterial phase CT scan in the same patient as in b demonstrates not only the dominant right lobe lesion but also multiple small hypervascular lesions (arrows) in the anterior portion of the right lobe and throughout all segments of the left lobe. This information aids the surgeon in designating this cancer as inoperable. If the portal venous phase image alone had been obtained, a different decision might have been made.

View larger version (120K): [in a new window]   Figure 4a. Detection of colon polyps in the 1950s was accomplished by means of single-contrast barium enema studies. Fifty years later, imaging for detection of polyps has evolved to include CT colonography and, perhaps, MR colonography. (a) Single-contrast barium enema study obtained in 1959 demonstrates a polyp (arrow) with a long stalk. (b) CT colonographic image obtained in a different patient in 1999 illustrates the ability of this technique to characterize the colonic surface and lumen and aid in detection of smaller sessile polyps (arrows).

View larger version (91K): [in a new window]   Figure 4b. Detection of colon polyps in the 1950s was accomplished by means of single-contrast barium enema studies. Fifty years later, imaging for detection of polyps has evolved to include CT colonography and, perhaps, MR colonography. (a) Single-contrast barium enema study obtained in 1959 demonstrates a polyp (arrow) with a long stalk. (b) CT colonographic image obtained in a different patient in 1999 illustrates the ability of this technique to characterize the colonic surface and lumen and aid in detection of smaller sessile polyps (arrows).

View larger version (147K): [in a new window]   Figure 5a. The radiologic evaluation of intestinal ischemia was, for the most part, confined to abdominal radiography in the 1950s. Fifty years later, the use of helical CT with CT angiography has greatly increased the sensitivity and specificity of imaging for ischemic bowel. (a) Radiograph in a patient (supine position) with abdominal pain and metabolic acidosis who was suspected of having intestinal ischemia demonstrates dilated bowel but no specific features of intestinal ischemia. In this setting, the only way to establish a diagnosis was with laparotomy. At surgery, it was discovered that the patient had extensive advanced infarction. Had helical CT been available, the diagnosis would have been confirmed preoperatively. (b) Transverse CT scan in a different patient demonstrates an embolus (arrow) in the superior mesenteric artery of a patient with atrial fibrillation; the patient was suspected of having intestinal ischemia. (c) Transverse CT scan in the same patient as in b shows extensive air (arrows) in the bowel wall of segments of jejunum, which permitted a diagnosis of intestinal infarction due to superior mesenteric arterial hypoperfusion. (Fig 5b and 5c courtesy of R. Brooke Jeffrey, Jr, MD, Department of Radiology, Stanford University, Calif.)

View larger version (162K): [in a new window]   Figure 5b. The radiologic evaluation of intestinal ischemia was, for the most part, confined to abdominal radiography in the 1950s. Fifty years later, the use of helical CT with CT angiography has greatly increased the sensitivity and specificity of imaging for ischemic bowel. (a) Radiograph in a patient (supine position) with abdominal pain and metabolic acidosis who was suspected of having intestinal ischemia demonstrates dilated bowel but no specific features of intestinal ischemia. In this setting, the only way to establish a diagnosis was with laparotomy. At surgery, it was discovered that the patient had extensive advanced infarction. Had helical CT been available, the diagnosis would have been confirmed preoperatively. (b) Transverse CT scan in a different patient demonstrates an embolus (arrow) in the superior mesenteric artery of a patient with atrial fibrillation; the patient was suspected of having intestinal ischemia. (c) Transverse CT scan in the same patient as in b shows extensive air (arrows) in the bowel wall of segments of jejunum, which permitted a diagnosis of intestinal infarction due to superior mesenteric arterial hypoperfusion. (Fig 5b and 5c courtesy of R. Brooke Jeffrey, Jr, MD, Department of Radiology, Stanford University, Calif.)

View larger version (126K): [in a new window]   Figure 5c. The radiologic evaluation of intestinal ischemia was, for the most part, confined to abdominal radiography in the 1950s. Fifty years later, the use of helical CT with CT angiography has greatly increased the sensitivity and specificity of imaging for ischemic bowel. (a) Radiograph in a patient (supine position) with abdominal pain and metabolic acidosis who was suspected of having intestinal ischemia demonstrates dilated bowel but no specific features of intestinal ischemia. In this setting, the only way to establish a diagnosis was with laparotomy. At surgery, it was discovered that the patient had extensive advanced infarction. Had helical CT been available, the diagnosis would have been confirmed preoperatively. (b) Transverse CT scan in a different patient demonstrates an embolus (arrow) in the superior mesenteric artery of a patient with atrial fibrillation; the patient was suspected of having intestinal ischemia. (c) Transverse CT scan in the same patient as in b shows extensive air (arrows) in the bowel wall of segments of jejunum, which permitted a diagnosis of intestinal infarction due to superior mesenteric arterial hypoperfusion. (Fig 5b and 5c courtesy of R. Brooke Jeffrey, Jr, MD, Department of Radiology, Stanford University, Calif.)