1

Sllavko K. Kallfa





Prmbledhje Artikujsh nga
Radiopaedia.org
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poultry and fowl
X-ray signs


o beak sign........................................f.3
o beak sign of sigmoid volvulus f.4
o bird-beak sign................................f.6
o eggshell calcification......................f.20
o gull wing appearance.....................f.28
o hummingbird sign.........................f.36
o sitting duck appearance................f.42
o swan neck deformity.....................f.43
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Beak sign of arterial dissection
Dr Jeremy Jones and Dr Yale Rosen et al.
The beak sign of arterial dissection represents a wedge of haematoma at the distal end of the
false lumen. It is here that false lumen propagation is occurring. It manifest as an acute angle
between the dissection flap and the outer wall. It may be filled with contrast enhanced blood
(high attenuation) or thrombus (low attenuation)
References
1. LePage MA, Quint LE, Sonnad SS et-al. Aortic dissection: CT features that distinguish
true lumen from false lumen. AJR Am J Roentgenol. 2001;177 (1): 207-11. AJR Am J
Roentgenol (full text) [pubmed citation]










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Sigmoid volvulus
Dr Henry Knipe and Dr Jeremy Jones et al.
Sigmoid volvulus is a cause of large bowel obstruction and occurs when the sigmoid colon
tortes on the sigmoid mesocolon.
Epidemiology
Large bowel volvulus accounts for ~5% of all large bowel obstructions, with ~60% of intestinal
volvulus involving the sigmoid colon
6
. It is more common in the elderly
7
.
Clinical presentation
Symptoms are that of a large bowel obstruction - constipation, abdominal bloating, nausea and/or
vomiting. Onset may be acute or chronic.
Pathology
Aetiology
There is a wide range of causes, some are region-specific
5
:
chronic constipation and/or laxative abuse
fibre-rich diet (especially in Africa)
Chagas disease (especially in South America)
Associations
chronic neurological conditions (e.g. Parkinson disease, multiple sclerosis, pseudobulbar
palsy)
chronic psychiatric conditions (e.g. chronic schizophrenia)
Radiographic features
Sigmoid volvulus is differentiated from a caecal volvulus by its ahaustral wall and the lower end
pointing to pelvis.
Plain film
Abdominal radiographs will demonstrated a large, dilated loop of colon, often with a few air-
fluid levels. Specific signs include:
coffee bean sign
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Frimann Dahl's sign - three dense lines converge towards site of obstruction
absent rectal gas
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5

Fluoroscopy
Although now uncommonly performed, a water soluble contrast enema exquisitely demonstrates
this condition, with the appearances described as the bird of prey sign.
CT
large gas-filled loop without haustral markings, forming a closed-loop obstruction
6, 7

whirl sign - twisting of the mesentery and mesenteric vessels
beak sign - if rectal contrast has been administered
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Treatment and prognosis
Rectal tube insertion is successful in successful in treating 90% of cases
5
. Mortality rate is 20-
25%
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. The most serious complication is bowel ischaemia.
Differential diagnosis
large bowel obstruction from other causes
caecal volvulus
colonic pseudo-obstruction
References
1. Janzen DL, Heap SW. Organo-axial volvulus of the sigmoid colon. Australas Radiol.
1992;36 (4): 332-3. - Pubmed citation
2. Catalano O. Computed tomographic appearance of sigmoid volvulus. Abdom Imaging.
21 (4): 314-7. Abdom Imaging (link) - Pubmed citation
3. Levsky JM, Den EI, Dubrow RA et-al. CT findings of sigmoid volvulus. AJR Am J
Roentgenol. 2010;194 (1): 136-43. doi:10.2214/AJR.09.2580 - Pubmed citation
4. Burrell HC, Baker DM, Wardrop P et-al. Significant plain film findings in sigmoid
volvulus. Clin Radiol. 1994;49 (5): 317-9. - Pubmed citation
5. Salati U, Mcneill G, Torreggiani WC. The coffee bean sign in sigmoid volvulus.
Radiology. 2011;258 (2): 651-2. doi:10.1148/radiol.101882 - Pubmed citation
6. Vandendries C, Julls MC, Boulay-Coletta I et-al. Diagnosis of colonic volvulus:
findings on multidetector CT with three-dimensional reconstructions. Br J Radiol.
2010;83 (995): 983-90. doi:10.1259/bjr/35714052 - Free text at pubmed - Pubmed
citation
7. Brant WE, Helms CA. Fundamentals of Diagnostic Radiology. Lippincott Williams &
Wilkins. (2007) ISBN:0781761352. Read it at Google Books - Find it at Amazon
Synonyms & Alternative Spellings
Synonyms or Alternative Spelling Include in Listings?
Sigmoid colon volvulus

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Bird-beak sign
Dr Jeremy Jones and Dr Frank Gaillard et al.
The bird-beak sign is used to refer to the tapering of the inferior oesophagus in achalasia. The
same appearance (although it is difficult to see the similarity) is also referred to as the rat-tail
sign.
The appearances although classically occurring in primary achalasia, can also occur in
pseudoachalasia due to a gastric tumour involving the gastro-oseophageal junction.
References
1. Patil KK, Telmesani A, Ogunbiyi OA. Childhood achalasia-a case report. West Afr J
Med. 1994;12 (3): 172-4. Pubmed citation
Synonyms & Alternative Spellings
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Bird beak sign

7

Bird Beak Bird head (with
beak) for bird-beak sign of achalasia. Author: DschwenOriginal file:
http://commons.wikimedia.org/wiki/File:Gull_portrait_ca_usa.jpgI, the copyright holder of this
work, hereby publish it under the following licenses: Permission is granted to copy, distribute
and/or modify this document under the terms of the GNU Free Documentation License, Version
1.2 or any later version published by the Free Software Foundation; with no Invariant Sections,
no Front-Cover Texts, and no Back-Cover Texts. A copy of the license is included in the section
entitled "GNU Free Documentation License".













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Achalasia
From the case: Achalasia
Modality: X-ray
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From the case: Achalasia
Modality: X-ray
10

From the case: Cardiac
achalasia
Modality: Barium
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12

13

14

15

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17

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From the case: Cardiac
achalasia
Modality: Barium
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From the case:
Achalasia
Modality: Barium



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Eggshell calcification
Dr Frank Gaillard et al.
Eggshell calcification refers to fine calcification seen at the periphery of a mass, and usually
relates to lymph node calcification.
In 1967 Jacobsen and Felson published criteria to help "avoid over-reading of the incidental
circumferential concentrations of calcium and to eliminate confusion with the ring shadows of
bronchi on end." These criteria were:
shell-like calcifications up to 2 mm thick must be present in the peripheral zone of at least
two lymph nodes
the calcifications may be solid or broken
in at least one of the lymph nodes the ringlike shadow must be complete
the central part of the lymph node may show additional calcifications
one of the affected lymph nodes must be at least 1 cm in its greatest diameter
Causes include
In the mediastinum and thorax
silicosis - 5% patients
treated lymphoma: (postirradiation Hodgkin disease) usually 1-9 years following
treatment
coal workers' pneumoconiosis (CWP) - 1% patients
sarcoidosis - calcification is uncommon (only 5% of patients) and occurs late in the
disease; only rarely does it have eggshell configuration
scleroderma
amyloidosis - rare
blastomycosis (e.g. pulmonary blastomycosis) - rare
histoplasmosis (e.g. pulmonary histoplasmosis) - rare
In the breast
oil cysts - in egg-shell calcification within the breast
Differential diagnosis
For eggshell like calcification appearances in the thorax consider
aneurysms
parathyroid tumours
pulmonary arteries in pulmonary arterial hypertension
thymic cysts
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thyroid tumours and multinodular goitre
References
1. Weissleder R. Primer of diagnostic imaging. Mosby Inc. (2007) ISBN:0323040683.
Read it at Google Books - Find it at Amazon
2. Wright FW. Radiology of the Chest and Related Conditions. CRC. (2001)
ISBN:0415281415. Read it at Google Books - Find it at Amazon
3. Gross BH, Schneider HJ, Proto AV. Eggshell calcification of lymph nodes: an update.
AJR Am J Roentgenol. 1980;135 (6): 1265-8. AJR Am J Roentgenol (citation) - Pubmed
citation
4. Jacobson G, Felson B et al "Eggshell calcifications in coal and metal miners." Semin
Roentgenol 1967; 2: 276-282
Synonyms & Alternative Spellings
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Eggshell calcifications
Eggshell calcifications - general

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Egg Photo by Ren West. This file is licensed by the author under Creative Commons NC BY SA 2.0
License. Visit case page for links.
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From the case:
Silicosis
Modality: CT
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25

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From the case:
Silicosis
Modality: CT
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From the case: Calcified oil cyst in right breast on CT
Modality: CT



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Gull wing appearance
Dr Henry Knipe and Dr MT Niknejad et al.
Gull-wing appearance is seen at erosive osteoarthritis on posteroanterior (PA) radiographs. The
combination of cartilage space loss, subchondral central erosions, and marginal
proliferation (osteophyte formation) results in a gull-wing appearance.
References
1. Chew FS. Radiology of the hands: review and self-assessment module. AJR Am J
Roentgenol. 2005;184 (6): S157-68. AJR Am J Roentgenol (full text) - Pubmed citation
Synonyms & Alternative Spellings
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Gull's wing appearance
Gull-wing appearance

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From the case: Seagull flying photo (creative commons)
Modality: Photo
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From the case: Gull-
wing appearance - erosive osteoarthritis
Modality: X-ray
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From the case: Gull-
wing appearance - erosive osteoarthritis
Modality: X-ray
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From the case: Erosive osteoarthritis
Modality: X-ray
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From the case: Erosive osteoarthritis
Modality: X-ray




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Hummingbird sign
Dr Frank Gaillard et al.
The hummingbird sign, also known as the penguin sign, refers to the appearance of the
brainstem in patients with progressive supranuclear palsy (PSP).
The atrophy of the midbrain results in a profile of the brainstem ( in the sagittal plane ) in which
the persevered pons forms the body of the bird, and the atrophic midbrain the head, with beak
extending anteriorly towards the optic chiasm.
References
1. Grschel K, Kastrup A, Litvan I et-al. Penguins and hummingbirds: midbrain atrophy
in progressive supranuclear palsy. Neurology. 2006;66 (6): 949-50.
doi:10.1212/01.wnl.0000203342.77115.bf - Pubmed citation
2. Shukla R, Sinha M, Kumar R et-al. 'Hummingbird' sign in progressive supranuclear
palsy. Ann Indian Acad Neurol. 2009;12 (2): 133. doi:10.4103/0972-2327.53087 - Free
text at pubmed - Pubmed citation
Synonyms & Alternative Spellings
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Penguin sign

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From
the case: Progressive supranuclear palsy - with hummingbird or penguin sign
Modality: MRI
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T2
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T1
From the case: Hummingbird sign in PSP
Modality: MRI
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From the case: Progressive supranuclear palsy
Modality: CT
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From the case: Hummingbird appearance in midbrain atrophy
Modality: MRI



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Sitting duck appearance
Dr Henry Knipe and Dr Mohammed Wahba et al.
The sitting duck appearance denotes the normal anatomical configuration of the jugular
foramen:
the head of the duck (pointing backwards on the right side) represents the anteromedial
pars nervosa
the body of the duck representing the pars vascularis
References
1. Swartz JD, Loevner LA. Imaging of the Temporal Bone. Thieme. (2009)
ISBN:1588903451. Read it at Google Books - Find it at Amazon
Annotated CT at the level of
the jugular foramen.

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Swan neck deformity
Dr MT Niknejad et al.
The swan neck deformity is one of the musculoskeletal manifestation of rheumatoid arthritis in
hand with:
hyperextension of the proximal interphalangeal (PIP) joints, and
compensatory flexion of the distal interphalangeal (DIP) joints
References
1. Longo D, Fauci AS, Kasper D et-al. Harrison's Principles of Internal Medicine.
McGraw-Hill Professional Pub. (2011) ISBN:007174889X. Read it at Google Books -
Find it at Amazon
2. Weissleder R, Wittenberg J, Harisinghani MG. Primer of diagnostic imaging. Mosby
Inc. (2007) ISBN:0323040683. Read it at Google Books - Find it at Amazon
Synonyms & Alternative Spellings
Synonyms or Alternative Spelling Include in Listings?
Swan neck type deformity

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From the case: Swan neck deformity- post traumatic
Modality: X-ray