Radiology

Lim Su Ann
FY1
UGI&Pancreas Surgery/Radiology/Elderly

Aims
CXR
- ABCDE features

AXR
-Bowel obstruction
-IBD features
-Volvulus

X Ray
A form of electomagnetic radiation
Absorbed to a variable extent
Visibility dependent on density

2 dimensional image

CXR Interpretation
Demographics
Date of X ray
Frontal PA/AP
Lateral
RIP ABCDE
Everyone has their own method

R- Rotation
I- Inspiration
P- Penetration
A- Airway
B- Breathing/Bones
C- Cardiac
D- Diaphragm
E- Everything else!

Anatomy

Normal Chest
X Ray

How to describe?
1) What?

- Shape
- Edge
- Size
2) Where?

- Side
- Lobe/zone

- Distribution

Useful keywords
Opacification
Well-defined/ill-defined
Reticulonodular shadowing
Contour
Nodular
Lymphadenopathy

A- Airway
Trachea central?
Common causes of deviated trachea:
- Tension pneumothorax
- Pulmonary collapse
- Large pleural effusion
- Kyphoscoliosis
- Lung carcinoma

B- Breathing
Lung fields- snake pattern
- Consolidation/Mass
- Effusion
- Collapse

Lung margins including mediastinum/hila region

R hilum higher than Left
Widened mediastinum causes:
- Hilar lymphadenopathy (Sarcoidosis, TB, Lymphoma)
- Aortic Aneurysm

B cont
Silhouette sign
- RUL: apex
- RML: R heart border
- RLL: Diaphragm
- LUL/lingula: L heart border
- LLL: Diaphragm

C- Cardiac
Size- Cardiomegaly >1/2 cardiothoracic ratio
Heart borders
Look for signs of heart failure
-A : Alveolar oedema (Bats wing)
-B : Kerley B lines (interstitial oedema)
-C : Cardiomegaly
-D : Upper lobe Diversion
-E : Pleural Effusion

D- Diaphragm
R side usually SLIGHTLY higher (due to liver)
(usually ~level of 6th anterior rib)
Causes of unilateral raised hemidiaphragm:
- Reduced lung volume
- Phrenic nerve palsy
- Tumour below diaphragm

cont
Pneumoperitoneum
- Perforation from abdominal viscus
- Post laparotomy/laparoscopy

E- Everything else!
Any lines/tubes/devices?- NG/central
line/pacemaker
Soft tissues
Bones- fracture (new/old), osteopaenia, bone mets
(sclerotic/lytic)
Review areas- esp apex and hilar region

NG tube
Aspirate>5 or unable X ray!

1) Follows the line of oesophagus?

2) Bisects carina?
3) Cross the diaphragm in midline?
4) At least 5cm below diaphragm?

Other Line Positions

1) CVC
-Common faults: Too low (in R atrium), too high (not in SVC), in
contralateral vessels

2) Chest drain
-Lies in thorax
-For pneumothorax or pleural effusion

3) Endotracheal tube
-Should project over lucent line of trachea
-Tip above carina

Tension
pneumothora
x

RML
consolidation

Case courtesy of Dr Sajoscha Sorrentino, Radiopaedia.org

LUL
pneumonia/ling
ular pneuomnia

Left hilar lung

mass

Pulmonary metastases
(Cannonball) from
RCC

ARDS

Miliary TB

Aortic
aneurysm

Bilateral hilar
lymphadenopathy

LLL collapse- sail sign

Left sided
pneumothorax

Left sided pleural

effusion

Right sided pleural

effusion with chest
drain in situ

Heart failure
ABCDE

Elevated R
hemidiaphragm

Pneumoperitoneum

Correct NG tube
placement

Misplaced NG tube

Dual chamber
pacemaker

CVC line

Abdominal X Ray
Demographics
Date of film
AP supine usually
Adequate film?- From diaphragm to pubis
Obvious abnormality first

What to look for?

Gasses, masses, bones and stones
1) Gasses
-) Bowels: Large/Small
-) Extraluminal
2) Masses
-) R/v all organs: Liver, Spleen,
Kidneys, Bladder
-) R/v retroperitoneal shadow of
psoas muscle

3) Bones
- Ribs, Spine, Sacrum, Pelvis
- Degeneration?
- Lytic/Sclerotic lesions
- RA/OA
4) Stones (Calcification)
- Renal, ureteric and bladder
- Gallstones, pancreatic
calcification

Bowel obstruction
Bowel-

Large

Small

Position

Periphery

Central

Size (obstruction)

> 5cm (caecum up to

8cm)

>3cm

Features

Haustra

Valvulae conniventes

Paralytic Ileus
One/both bowels
AIRFILLED but NOT dilated
NO clinical features of obstruction
Usually post surgery- day 4
Some describe it as both large and small bowel
looking the same
If localised- Sentinal loop/sign

Paralytic ileus pic/sentinal

loop

Volvulus
Most commonSigmoid and caecal volvulus
Twisting of bowel
Can lead to perforation or ischaemia

Sigmoid volvulus

Sigmoid volvulus

Caecal volvulus

Others
Toxic megacolon:
-Complication of IBD
- >6cm, usually transverse
colon
- May see thumbprinting
(oedema)

Lead pipe colon

Slideshow
A 79 yo woman was
brought into A&E after a
collapse. She complained
of hip pain.
1) What is your diagnosis?
2) What would you find on
examination?
3) What would the
management be?
1) Neck of femur fracture
2) Shortened and externally
rotated hip
3) Hemiarthroplasty

1) What test is this?

2) What and where is the
abnormality?

1) MR Angiogram of lower
limbs
2) Stenosis in the left
superficial femoral artery

A 45 year old woman

presented with SOB
and pleuritic chest
pain.
1) What is your
diagnosis?
2) How will you
manage this
patient?
1) Pulmonary embolus
2) ABCDE,
Anticoagulation
(LMWH as bridging
for warfarin)

A 30 year old man

presented to the A&E.
1) What symptoms
would this patient
present with?
2) What is your
diagnosis?

1) Sudden onset loin

to groin pain
2) Renal colic

A 57 yo male
presented with
change in bowel
habit, bloody stools
and recent weight
loss.
1) What is this sign
called?
2) What is your
diagnosis?
1) Apple core sign
2) Colorectal
carcinoma

List of radiological
conditions to know
CXR
- All pneumonias-lobes
- Pleural effusion
- Cancer/mets
- Heart failure
- Pneumothorax +tension
- Lobe collapse
- Hilar lymphadenopathy
- Pneumoperitoneum
- Widened mediastinum

Abdo X Ray
- Small bowel obstruction
- Large bowel obstruction
- Pneumoperitoneum
- Toxic megacolon
- Sigmoid volvulus/caecal volvulus
- Renal calculus

Joint X Ray
- Usually knee- OA
- Any RA/OA will have obvious features!
- Fractures ESP NOF

MRI
- Stroke: infarct, haemorrhage
- Tumour inc lobe
- Atrophy
- Spinal cord compression
MRI Angiography
- Stenosis

CT
-CTPA for PE: saddle embolus

Barium swallow/enema
- Achalasia
- Oesophageal carcinoma
- Diverticulitis
- Colon carcinoma

Useful websites
http://www.wikiradiography.net/page/Interstitial+
vs+Alveolar+Lung+
Patterns
www.radiopaedia.org
www.radiologymasterclass.co.uk

Thank You!
Any Questions?