x rays

Radiographs

Surgical unit 1BBH

2Dr Sadia JaskaniPGT-SU-1

BBH

Abdominal X-Ray Projections:

•Supine 99%

•Erect

•Lateral decubitus.

Knowledge of the anatomy of the abdomen

allows localization of the abnormalities

observed on the AXR.

3Dr Sadia Jaskani

PGT-SU-1BBH

Copyright©2010 CompanynameFree template by Investintech PDF Solutions

Supine

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Erect

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Lateral decubitus

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Assess the Film in Detail:

A simple guide to interpretation is shown below. Working

through these headings one covers, ‘dark bits’, ‘white bits’,

‘grey bits’ and ‘bright white bits’ in turn.

‘BLACK BITS’

•Intra-luminal gas can be normal.

•Extra-luminal gas is abnormal.

•However, intra-luminal gas can be abnormal if

it is in the wrong place or if too much is seen.

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‘BLACK BITS’ (Continued) - Intra-luminal gas:

•The maximum normal diameter of the large bowel is 55mm.

•Small bowel should be no more than 35mm in diameter.

•The natural presence of gas within the bowel allows

assessment of caliber - although the amount varies between

individuals.

•The caecum is not said to be dilated

unless wider than 80mm.•Large and small bowel may be distinguished by looking at

bowel wall markings

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Characteristic Small bowelLarge bowel

Haustra Absent Present

Valvulae conniventesPresent in jejunum

Absent

Number of loops Many Few

Distribution of loops Central Peripheral

Radius of curvature of loop

Small Large

Diameter of loop 30–50 mm 50 mm+

Solid faeces AbsentMay be present

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The haustra of the large bowel extend only a third of the way across the bowel from each side, whereas the valvulae conniventes of the small bowel tranverse the complete distance.

Intra-luminal gas (continued):

It is usual to see small volumes of gas throughout the

GI tract and the absence in one region may in itself

represent pathology.

For example, if gas is seen to the level of the splenic

flexure and nothing is seen beyond this, a site of the

obstruction at this site – a ‘cut off’ point is noted.10

Dr Sadia JaskaniPGT-SU-1

BBH


Causes of Extra-luminal gas:

•Post Abdominal Surgery/ERCP

•Perforation of viscus (eg. bowel, stomach)

•Gallstone ileus

•Cholangitis (infection with gas forming organisms)

•Abscess

An erect CXR (not AXR) is the best

projection to diagnose a

pneumoperitoneum (gas in the peritoneal

cavity).

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‘WHITE BITS’ = Calcification

Calcified structures (‘WHITE BITS’) are often seen on

AXR.

The main question is – does its presence

have any important implications

Bones are normal ‘white’ structures. On the AXR they

comprise mainly those of the thoraco-lumbar spine and

pelvis. Findings are largely incidental as direct bone

pathology would be investigated with specific views.

12Dr Sadia Jaskani

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‘GREY BITS’ = Soft Tissues

Soft tissues represent most of the contents of the abdomen and feature heavily in the AXR. However, these tissues are poorly seen when compared to other imaging techniques such as ultrasound or CT.

The kidneys, spleen, liver and bladder (if filled) can be seen in addition to psoas muscle shadows and abdominal fat. Rarely would action be taken on the basis of this imaging alone.

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‘BRIGHT WHITE BITS’ = Foreign Bodies

•Foreign Bodies represent an interesting final

observation.

•Objects that may be seen include ingested and rectal

foreign bodies, items in the path of the x-ray beam such as

belt buckles, dress buttons and jewelry.

•Other objects may have been deliberately placed for

example an aortic stent, an inferior vena cava filter or a

suprapubic urinary catheter. Sterilization clips and an intra-

uterine device are common findings in women.

14Dr Sadia Jaskani

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mnemonic for what to do next

• Big Spanish Cuddly Giant Again

• (i.e. Bone, Soft tissue/Solid Organs,

Calcification, Gas pattern & Artefacts)

but I feel sure you could come up

with your own

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Feeding tube

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CVP

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X-rays of GITA brief reveiw

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• A plain x ray of the abdomen in erect position shows multiple air fluid levels that indicate intestinal obstruction

• Intestinal obstruction may be • Dynamic, where peristalsis is working

against a mechanical obstruction• Adynamic, when there is no mechanical

element.

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• These plain x rays of the abdomen in the supine position show dilated jejunal loops that are charcterized by the valvulaeconvenintes(Looks like an accordion) and dilated illeal loop (stuctureless type) described by wagenstein

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• The obstructed small bowel is characterized by straight segments that are generally central and lie transversely. No gas is seen in the colon. The supine film is superior than the erect film

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• Valvulaeconniventiespass across the width of bowel and are regularly spaced

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• Rigglers sign: luminal and external border of the bowel are visible

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sigmoid volvulus

• Plain x ray abdomen

• twisting or axial rotation of sigmoid colon about its mesentry

• Omega sign/ coffee bean sign

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This is the coffee

bean sign

It is seen in sigmoid

volvulus

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Ceacal volvulus

• A barium enema may be used to confirm the diagnosis, with an absence of barium in the ceacum and a bird beak deformity

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duodenal atresia

• Double bubble appearance

• It occurs due to gross distension of stomach and upper duodenum

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free gas under the diaphragm

• X ray erect chest• Hollow viseral

perforation• Absence of gas

under diaphragm does not exclude the diagnosis of viseral perforation

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• X-ray erect chest---gas under diaphragm

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Inguinal hernia

• Distended gut loops at the level of deep inguinal ring

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X ray showing foreign body in the rectum

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X ray showing foreign body in the rectum



•This is the ‘bird beak’ sign

•It is seen in achalasia•It apparently looks like a bird’s beak (see

below)

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• Barium swallow x ray showing the dilated esophagus down to lower end, smooth tapering of lower esophagus(dysphagia)• Bird beak deformity• Rat tail appearance• Pencil tip sign

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This is an ‘apple-core’

lesion

These are almost always

cancer (in this case it is a

caecal carcinoma)

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Pyloric obstruction

• Huge sized stomach

• No dye seen beyond pyloric sphincter

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Leadpipe colon

• Barium enema showing loss of haustrationsand narrowing of sigmoid and descending parts of the colon

• Characteristic of ulcerative colitis

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Lead pipe colon!!

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String of kantor

• Seen in crohn's disease

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Endoscopic cholangiopancreatography


BBH


Clinical anatomy

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• ERCP• Showing

normal CBD and pancreatic duct.

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Filling defects in

CBD

• ERCP• Showing

dilated CBD

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• ERCP Showing stone in lower part of CBD and pancreatic duct.

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Gall stones


Gall stones

• Cholesterol and pigment stones are radiopaque and visible on radiographs in

only 10-30% of instances, depending on their extent

of calcification

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Porcelain Gall Bladder

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Pancreatic calcifications

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Renal pathology

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These are ‘stag-horn’

calculi

Do not confuse this with

an IVU; no contrast has

been used here

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X ray KUB

• showing radio opaque shadows consistent with renal stones

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Bladder calcifications.

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X ray showing urinary bladder stones

• Pure uric acid and ammonium urate stones are radiolucent

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Urinary bladder stones

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Intravenous urography

• Urinary bladded Filling

defect

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Mammographs


BBH


BI-RADS standardized categories

• Category 0, or "need additional imaging evaluation," is used if additional imaging is needed/screening situation

• Category 1, or "negative," is used if there are no findings to comment on

• Category 2, or "benign finding(s)," to describe a benign finding while still concluding that there is no mammographic evidence of malignancy.

• Category 3, when a noted finding has a very high probability of being benign• Category 4, or "suspicious abnormality–biopsy should be considered," is used

when a finding has a definite probability of being malignant\

• Category 5, or "highly suggestive of malignancy–appropriate action should be taken," is used when a finding has a high probability of being cancerous

• Category 6, or "known biopsy-proven malignancy-appropriate action should be taken," is "reserved for lesions identified on imaging study with biopsy proof of malignancy prior to definitive therapy"

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Normal mammogram

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Mammographic images showing well circumscribed mass, well defined

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Mamogram showing macrocalcifications

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Mammograph showing diffuse calcifications

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Chest x ray


Pneumothorax

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Peumothorax

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Hemothorax/hydrothorax/pyothorax

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Hemothorax

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Hemopneumothorax

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Hemopneumothorax

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Tension pneumothorax

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Flial chest

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Chest tube

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Chest tube

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Mesothelioma

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CA lung

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ARDS

79Dr Sadia Jaskani

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Cardiac temponade

80Dr Sadia Jaskani

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Aspergilloma

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Ct scan


BBHc


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Normal anatomy

84Dr Sadia Jaskani

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Trauma situations

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CT scan brain


BBH


Extradural hematoma

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Subdural hematoma

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Subarachanoid hamorrhage

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Intraparenchymal bleed

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Base of skull fracture

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Depressed skull fracture


BBH



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All the best


BBH


x rays

Education

present9dr sadia jaskanipgtsu

extraluminal gas

pneumoperitoneum gas

small volumes of gas

grey bits

black bitsintraluminal

small bowel tranverse

bright white bits