2005 Radiology Exam - Alternate Imaging Case 2

Information Provided to Candidate
1. Canine: English Springer Spaniel, male castrate 2 years old
2. 1 week history of anorexia and intermittent vomiting.
3. As part of the diagnostic workup a barium upper gastrointestinal study was done.
4. Radiographs at 0, 1, 2, and 6 hours  were provided.

State the radiographic findings

  • Give a concise assessment.
  • Any further imaging studies needed? If not, why not? If yes, what studies are indicated and why?

See images below. Click to enlarge.

Findings Expected from Candidate
Adequate volume of barium was administered. The duodenum and proximal jejunum are irregular in contour and margination, with a pleated appearance, most apparent on the initial ‘0’ time images. At ‘0’ time there is a linear filling defect in the most proximal duodenum. Over time there is persistent barium opacification of the duodenum and pylorus and the barium within the duodenum develops a heterogeneous appearance. A short segment of mid jejunum has similar changes. There is a mild delay in gastrocolic transit time. On the ‘0’ time lateral image, there are a number of angular more geometric shaped gas patterns in the jejunum.

Conclusion Expected from the Candidate
The radiographic changes are most consistent with a linear foreign body within the pyloric outflow tract and duodenum. The heterogeneous/streaking appearance to the barium is commonly seen with absorbing cloth type material. An additional foreign body is likely present in the mid jejunum.
Images made at 6 hours were available on request. Given that the stomach wasn’t empty at 2 hours and the persistent pyloric and duodenal opacification, continuing the study is a reasonable strategy. Also, cloth type foreign bodies often become more apparent over time as they absorb barium and luminal barium is passed.

Summary of Overall Candidate Performance
All candidates recognized the pyloric and duodenal changes. However, the changes were often interpretated as infiltrative/inflammatory bowel disease or diffuse adenocarcinoma, with no mention of a foreign body as a differential, and the patient sent for endoscopic biopsies or placed on immunosuppressive therapy. The signalment and history are strong clues in this case and support the radiographic findings.