Radiology

RadiologyLim Su Ann FY1 UGI&Pancreas Surgery/Radiology/ElderlyAimsCXR- ABCDE features

AXR-Bowel obstruction-IBD features-Volvulus

X RayA form of electomagnetic radiationAbsorbed to a variable extent Visibility dependent on density

2 dimensional image

X ray-map of attenuationVariable depending of density and thickness of tissue5 X ray densities- spectrumMore dense and thick, more white

Pass through air- least absorbed (most blackening), calcium absorbs most. generated by an X-ray tube, a vacuum tube that uses a high voltage to accelerate the electrons released by a hot cathode to a high velocity

Radiologymasterclasshttp://www.nle.nottingham.ac.uk/websites/abdominal_radiology/densities.html3CXR InterpretationDemographicsDate of X rayFrontal PA/APLateralRIP ABCDEEveryone has their own method

R- RotationI- InspirationP- PenetrationA- AirwayB- Breathing/BonesC- CardiacD- DiaphragmE- Everything else! Anatomy

http://www.aboutcancer.com/mediastinal_contents_PA_Virginia.jpghttp://anatomylist.com/neck-anatomy-lateral-x-ray.html5

Normal Chest X RayExplain features seen wikipaediaGo through ABCDE here

6How to describe?1) What?ShapeEdge Size 2) Where?SideLobe/zone- Distribution

Shape- circular/patchy/contour/nodularEdge- Well defined/Ill definedSizeSide- L or R or bilateralLobeDistribution- Widespread/Solitary7Useful keywordsOpacificationWell-defined/ill-definedReticulonodular shadowingContourNodularLymphadenopathy A- AirwayTrachea central? Common causes of deviated trachea:Tension pneumothoraxPulmonary collapseLarge pleural effusionKyphoscoliosisLung carcinoma

Away from affected lung- Tension pneumothorax, large pleural effusion, 9B- BreathingLung fields- snake patternConsolidation/MassEffusionCollapseLung margins including mediastinum/hila regionR hilum higher than Left Widened mediastinum causes: Hilar lymphadenopathy (Sarcoidosis, TB, Lymphoma)Aortic Aneurysm Lose silhouette as same density10B contSilhouette signRUL: apexRML: R heart border RLL: DiaphragmLUL/lingula: L heart borderLLL: Diaphragm

C- CardiacSize- Cardiomegaly >1/2 cardiothoracic ratioHeart bordersLook for signs of heart failure -A : Alveolar oedema (Bats wing)-B : Kerley B lines (interstitial oedema)-C : Cardiomegaly-D : Upper lobe Diversion-E : Pleural EffusionD- DiaphragmR side usually SLIGHTLY higher (due to liver)(usually ~level of 6th anterior rib)Causes of unilateral raised hemidiaphragm:Reduced lung volume Phrenic nerve palsyTumour below diaphragmReduced lung volume- post lobectomy/pneumonectomy, lobar collapse, 13contPneumoperitoneumPerforation from abdominal viscus Post laparotomy/laparoscopyperforated hollow viscus:peptic ulcer diseaseischaemic bowelbowel obstructionnecrotising enterocolitisappendicitisdiverticulitis14E- Everything else!Any lines/tubes/devices?- NG/central line/pacemakerSoft tissuesBones- fracture (new/old), osteopaenia, bone mets (sclerotic/lytic)Review areas- esp apex and hilar region

Soft tissues- breast shadow? Mastectomy? Surgical emphysema15NG tubeAspirate>5 or unable X ray!

Follows the line of oesophagus?Bisects carina?Cross the diaphragm in midline?At least 5cm below diaphragm?Other Line Positions 1) CVC-Common faults: Too low (in R atrium), too high (not in SVC), in contralateral vessels2) Chest drain-Lies in thorax-For pneumothorax or pleural effusion3) Endotracheal tube-Should project over lucent line of trachea-Tip above carina Read through yourself, not going through much today17

Tension pneumothoraxhttp://www.yale.edu/imaging/cases/pneumothorax_tension/index.htmlPneumothorax of left lungNote the marked density difference between the left and right thoracic cavities. The complete translucency on the left with absence of vascular markings is characteristic of a pneumothorax. What appears as a left hilar mass is in fact the collapsed left lung retracted into a small central density. The patient is incidentally a female whose breast shadows account for the change in density between the upper and lower lung fields.The pressure in the pleural space is normally 5 cm of water below atmospheric. If air is introduced into the pleural space and the visceral and parietal layers of the pleura allowed to separate, the lungs will begin to collapse and the thoracic cage will enlarge.

The post-treatment radiograph shows re-expansion of the left lung with reappearance of vascular markings after evacuation of pleural air by a chest tube.18

Case courtesy of Dr Sajoscha Sorrentino, Radiopaedia.orgRML consolidationConsolidationRML consolidation20

LUL pneumonia/lingular pneuomniaLeft lingular pneumonia- left upper lobehttp://www.yale.edu/imaging/cases/pneumonia_lingular/index.html21

Left hilar lung massCase courtesy of Dr Frank Gaillard, Radiopaedia.orgLung cancer- left hilar region

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Pulmonary metastases (Cannonball) from RCCCannonball mets- RCCwww.ccij-online.org23

ARDSARDSCase courtesy of Dr Frank Gaillard, Radiopaedia.orgCloud-like appearance- alveolar shadowingNormal heart size, no pleural effusion- non cardiogenic causeCommon causes- pneumonia, haemorrhage, renal/liver failure24

Miliary TBhttp://www.learningradiology.com/archives2007/COW%20277-Miliary%20TB/miliarytbcorrect.htmlReticulonodular shadowing- miliary tb/tb

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Aortic aneurysmhttp://www.yale.edu/imaging/cases/aortic_aneurysm/index.html26

Bilateral hilar lymphadenopathyBilateral hilar lymphadenopathyhttp://www.learningradiology.com/archives03/COW%20078-Sarcoid%20lung/sarcoidcorrect.htm27

LLL collapse- sail signSail sign- LLL collapsehttp://www.revise4finals.co.uk/medicine/multimedia/chestxrayabnorm.php28

Left sided pneumothoraxL sided pneumothorax- no mediastinal shifthttp://rrapid.leeds.ac.uk/ebook/04-breathing-05.html

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Left sided pleural effusionL sided pleural effusionhttp://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/cxr/ple1.htm30

Right sided pleural effusion with chest drain in situR sided pleural effusion with chest drain in situ

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Heart failureABCDEhttps://www.med-ed.virginia.edu/courses/rad/cxr/pathology2Bchest.htmlHeart failure- ABCDE

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Elevated R hemidiaphragmCase courtesy of Dr Frank Gaillard, Radiopaedia.orgElevated R hemidiaphragm33

PneumoperitoneumCase courtesy of Dr Frank Gaillard, Radiopaedia.orgpneumoperitoneum34

Correct NG tube placementCase courtesy of Dr Ian Bickle, Radiopaedia.org35

Misplaced NG tube Case courtesy of Dr Jeremy Jones, Radiopaedia.orgWRONG NG position36

Dual chamber pacemakerCase courtesy of Dr Usman Bashir, Radiopaedia.org37

CVC lineCase courtesy of Dr Henry Knipe, Radiopaedia.org38Abdominal X RayDemographicsDate of filmAP supine usuallyAdequate film?- From diaphragm to pubisObvious abnormality firstWhat to look for?Gasses, masses, bones and stonesGassesBowels: Large/SmallExtraluminal2) MassesR/v all organs: Liver, Spleen, Kidneys, BladderR/v retroperitoneal shadow of psoas muscle

3) BonesRibs, Spine, Sacrum, PelvisDegeneration?Lytic/Sclerotic lesionsRA/OA4) Stones (Calcification)Renal, ureteric and bladderGallstones, pancreatic calcification

Bowel obstructionBowel-LargeSmallPositionPeripheryCentralSize (obstruction)> 5cm (caecum up to 8cm)>3cmFeaturesHaustraValvulae conniventes

reflex ileus are numerous including abdominal inflammations and infections, chemical and pharmacological causes, trauma and abscess.Case courtesy of Dr Jeremy Jones, Radiopaedia.orghttp://www.swansea-radiology.co.uk/tm_abdominal_radiograph_lbo.html

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Paralytic Ileus

One/both bowelsAIRFILLED but NOT dilatedNO clinical features of obstructionUsually post surgery- day 4Some describe it as both large and small bowel looking the sameIf localised- Sentinal loop/sign

Paralytic ileus pic/sentinal loop

Sentinel loophttp://www.learningradiology.com/radsigns/radsignspages/S-radsigns.htm44VolvulusMost common- Sigmoid and caecal volvulusTwisting of bowelCan lead to perforation or ischaemia

Sigmoid volvulusThe sigmoid colon is more prone to twisting than other segments of the large bowel because it is 'mobile' on its own mesentery, which arises from a fixed point in the left iliac fossa (LIF). Twisting at the root of the mesentery results in the formation of an enclosed loop of sigmoid colon which becomes very dilated. If untreated this can lead either to perforation, due to excessive dilatation, or to ischaemia due to compromise of the blood supply.http://radiologymasterclass.co.uk/tutorials/abdo/abdomen_x-ray_abnormalities/pathology_obstruction_volvulus.html45

Sigmoid volvulusSigmoid volvulus - 'coffee bean' signThe sigmoid colon is very dilated because it is twisted at the root of its mesentery in the left iliac fossa (LIF). The proximal large bowel is also dilated (asterisks).The twisted loop of sigmoid colon is said to resemble a coffee bean. As in this case the loop of dilated sigmoid colon - or 'coffee bean' - usually points upwards towards the diaphragm.This patient is at high risk of perforation and/or bowel ischaemia.Case courtesy of Dr Wael Nemattalla, Radiopaedia.orgSigmoid volvulus is a cause of large bowel obstruction and occurs when the sigmoid colon tortes on the sigmoid mesocolon.46

Sigmoid volvulusCase courtesy of Dr Henry Knipe, Radiopaedia.orghttp://radiopaedia.org/articles/sigmoid-volvulus47

Caecal volvulusCase courtesy of Dr Ian Bickle, Radiopaedia.orgMarked distension of a loop of large bowel with its long axis extending from the right lower quadrant to the epigastrium or left upper quadrant. Depending on the initial bowel position and the length of mobile right colon, the distended caecum may be seen anywhere in the abdomen.

Despite the varying positions of the distended cecum, the plain radiographic features of a caecal volvulus are characteristic, and the caput caecum can typically be identified. The colonic haustral pattern is generally maintained in contradistinction to a sigmoid volvulus although some effacement may be present if ischemia develops.

When shorter segments of the colon and cecum are involved, the distended caecum may be found in the normal location. In most patients, obstruction is almost complete and the distal colon is usually empty and the small bowel frequently distended.48Others

Toxic megacolon:

-Complication of IBD

>6cm, usually transverse colonMay see thumbprinting (oedema)

"Toxisches Megacolon bei Colitis ulcerosa" by Hellerhoff - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Toxisches_Megacolon_bei_Colitis_ulcerosa.jpg#mediaviewer/File:Toxisches_Megacolon_bei_Colitis_ulcerosa.jpgToxic megacolon49

Toxic megacolonThe colon is very dilated in this patient with acute abdominal pain, sepsis, and a known history of ulcerative colitis. The clinical features and X-ray appearances are consistent with toxic megacolon.There is evidence of bowel wall oedema with 'thumbprinting', and pseudopolyps or 'mucosal islands' (red-patches).http://radiologymasterclass.co.uk/tutorials/abdo/abdomen_x-ray_abnormalities/pathology_inflammatory_bowel.html50

Thumbprinting (mucosal thickening) The distance between loops of bowel is increased (arrows) due to thickening of the bowel wall. The haustral folds are very thick (arrowheads), leading to a sign known as 'thumbprinting.http://radiologymasterclass.co.uk/tutorials/abdo/abdomen_x-ray_abnormalities/pathology_inflammatory_bowel.html51

Lead pipe colonLead pipe colonThis patient with ulcerative colitis has a featureless segment of transverse colon with shows loss of the normal haustral markings.This 'lead pipe' appearance is associated with longstanding ulcerative colitis.The distal bowel is always involved in this disease but, as there is no air in the descending colon, this segment of colon is not evidently abnormal.http://radiologymasterclass.co.uk/tutorials/abdo/abdomen_x-ray_abnormalities/pathology_inflammatory_bowel.html

52Slideshow

A 79 yo woman was brought into A&E after a collapse. She complained of hip pain.

What is your diagnosis?

What would you find on examination?

What would the management be?Neck of femur fractureShortened and externally rotated hipHemiarthroplastyCase courtesy of Dr Frank Gaillard, Radiopaedia.org53

What test is this?

What and where is the abnormality?MR Angiogram of lower limbs

Stenosis in the left superficial femoral artery

http://www.rjmatthewsmd.com/Definitions/peripheral_vascular_disease.htmPeripheralart-figPeripheralart-fig18:Lower-extremity atherosclerotic arterial disease. This magnetic resonance angiogram (MRA) of the lower extremities was obtained by using the bolus-chase technique. A short-segment high-grade stenosis is present in the middle of the left superficial femoral artery. Note the collateral arterial supply.54

A 45 year old woman presented with SOB and pleuritic chest pain.

What is your diagnosis?

How will you manage this patient?Pulmonary embolusABCDE, Anticoagulation (LMWH as bridging for warfarin)"SADDLE PE". Licensed under Public Domain via Wikipedia - http://en.wikipedia.org/wiki/File:SADDLE_PE.JPG#mediaviewer/File:SADDLE_PE.JPG55

A 30 year old man presented to the A&E.

What symptoms would this patient present with?

2) What is your diagnosis?

Sudden onset loin to groin pain

Renal colic

Case courtesy of Dr Frank Gaillard, Radiopaedia.org56

A 57 yo male presented with change in bowel habit, bloody stools and recent weight loss.

What is this sign called?

What is your diagnosis?

Apple core signColorectal carcinomaCase courtesy of Dr Roberto Rafael Ovalle, Radiopaedia.org57List of radiological conditions to knowCXRAll pneumonias-lobesPleural effusionCancer/metsHeart failurePneumothorax +tensionLobe collapseHilar lymphadenopathyPneumoperitoneumWidened mediastinumAbdo X RaySmall bowel obstructionLarge bowel obstructionPneumoperitoneum Toxic megacolonSigmoid volvulus/caecal volvulusRenal calculusJoint X RayUsually knee- OAAny RA/OA will have obvious features!Fractures ESP NOFMRIStroke: infarct, haemorrhageTumour inc lobeAtrophySpinal cord compression MRI AngiographyStenosis CT-CTPA for PE: saddle embolus

Barium swallow/enemaAchalasiaOesophageal carcinomaDiverticulitisColon carcinoma

Useful websiteshttp://www.wikiradiography.net/page/Interstitial+vs+Alveolar+Lung+Patternswww.radiopaedia.orgwww.radiologymasterclass.co.uk

Thank You!Any Questions?