What are xrays?

A form of electromagnetic radiation with short wavelength (between 10-2 and 10 nm) X-rays are generated by using a high voltage current to accelerate electrons within evacuated glass tubes, towards a tungsten target How is an X-ray Image obtained? The X-rays pass through the body and are detected on photographic film placed behind the patient TYPES OF IMAGING IN RADIOLOGY DEPARTMENT X-RAYS ULTRASOUND COMPUTED TOMOGRAPHY (CT) NUCLEAR MEDICINE ANGIOGRAPHY MAGNETIC RESONANCE IMAGING (MRI) What is Ultrasound? Sound waves with frequencies above the range of human hearing ultra sound A narrow beam of high energy sound waves is directed into the patients body The manner in which the sound is reflected back from various tissues is recorded Why use ultrasound Cheaper than ct or mri Patient is not exposed to ionizing radiation Equipment is very portable therefore can be used for patients too sick or injured to be moved from their beds Ultrasonography noninvasive, inexpensive, widely available, it should still be used first whenever feasible The more invasive and expensive techniques such as CT and MRI should be reserved for those cases in which ultrasound has not been able to provide an answer to the clinical questions Ultrasonography has become the major screening modality in suspected disease of the parenchymal organs of the upper abdomen. It is also the imaging modality of choice for the evaluation of disease of The liver the gallbladder, the biliary tract, pancreas, abdominal aorta. Echo cardiogrphy Is adiagnostic test that uses ultrasound waves to create an image of the heart muscle Ultrasound show the size,shape,and movement of the heart valves and chambers as well as the flow of blood through the heart

 Echo cardigrphy show such anomalies as poorly functining heart valves or damage to heart tissue from apast heart attack What is computed tomography An xray based technique The xray tube and detector are rotate in aplane around the patient What is nuclear imaging A radioactive isotope is injected into the patient The isotope is taken by the organ and tissue of interest The isotope emits gama rays which are then detected by agama camera What is magnetic resonance imaging Involves measuring the behaviour of protons in different chemical enviroment when exposed to magnetic field Patient are not exposed to ionizing radiation Contraindications for MRI Cardiac pacekmakers Ferromagnetic aneurysm clips Metallic foreign body in critical structures like in the eye or spinal cord Neurostimulators (e.g. cochlear implants) Claustrophobia MR advantages Multiplanar imaging Tissue characterization No bone artifacts Shows blood vessels without contrast Hysterosalpingogram T-tube Cholangiogram. Normal Chest Imaging investigations of the chest: Plain films (chest x-ray). CT scanning. MRI. Ultrasound. Radionuclide studies. Computed Tomography Numerous protocols/techniques depending on clinical history Helical/spiral versus high resolution Contrast Renal failure Allergy Role of CT Main further investigation for most CXR abnormality (eg nodule/mass) or to exclude disease with normal CXR Main investigation for certain scenarios (PE, dissection, trauma) MRI Multiple planes

No radiation Common Indication Pancoast tumour Brachial plexus Cardiac Vascular (aorta) Usually targeted examination (unlike CT) Nuclear Medicine Variety of tests: functional rather than anatomic V/Q specific to chest imaging Others: bone scan, gallium, WBC etc. Ultrasound Limited use in thorax (non cardiac) due to air in lungs Assess pleural effusions Mainly used for procedures Normal chest X ray Chest films are the commonest xray examination. Chest films are also one of the most difficult plain films examination. Knowledge of the normal appearances of a chest radiograph is essential. The standard films of the chest are: Poster anterior (PA) Lateral Extra views Lordotic (apical). Lateral decubitus. Expiratory & inspiratory films. AP view. Chest Radiograph: Approach and Normal Anatomy THERE IS NO ONE APPROACH: BE SYSTEMATIC Bone and Soft Tissue including abdomen Heart Mediastinum-aorta, trachea Hila Pulmonary Vasculature Lungs Pleura Approach to Chest Radiograph: Technical Factors Patient Identification (name and date) Markers (Left vs right) Assess for rotation (clavicles vs spinous process) Penetration (thoracic spine should be visible) Degree of Inpiration: 6th anterior or 10th posterior Technical centering. marker. degree of inspiration. penetration. Inspiration/Expiration Images Expiration Heart size appear larger

 Hidden areas

Mediastinum is wider Pulmonary vasculature indistinct

1. apices. 2. diaphragm 3. mediastinum 4. hila 5. Bones 6. Soft tissues. Lung Anatomy Lobes are separated by fissures Right Upper Lobe Middle Lobe Lower Lobe Left Upper Lobe (includes lingula) Lower Lobe Pathology of the Chest The nature of the fluid The fluid may be blood, lymph, pus, transudate (protein content <30g/litre) or an exudate (protein content >30g/litre). The nature of the fluid can only be determined by visual and laboratory inspection of an aspirated specimen Transudates 1. Generalized salt and water retention, e.g., congestive heart failure, nephrotic syndrome, hypoalbuminemia 2. Ascites, e.g., cirrhosis, meigs syndrome, peritoneal dialysis 3. Vascular obstruction, e.g., superior vena cava obstruction Exudates 1. Infections diseases, e.g. TB, bacterial pneumonias, and other infectious diseases. 2. Tumor 3. Pulmonary infarction 4. Rheumatic diseases Haemothorax is caused by trauma, surgery, pulmonary infarction, rupture of an aneurysm or adhesions from a spontaneous pneumothorax, anticoagulant therapy or a coagulation disorder. Chylothorax is caused by trauma, thoracic surgery, or mediastinal malignancy. Pneumothorax A pneumothorax develops when air escapes into the pleural cavity allowing the underlying lung to collapse. Four different types of pneumothorax are described: Primary spontaneous pneumothorax.

 . Secondary pneumothorax Traumatic pneumothorax from (penetrating injuries of the chest wall Artificial or induced pneumothorax Primary spontaneous pneumothorax. Primary spontaneous pneumothorax is usually caused by rupture of small subpleural bullae 1 cm to 2cm in diameter at the lung apex. ( such as Marfan's syndrome) Secondary pneumothorax is common in chronic bronchitis and emphysema caused by rupture of subpleural bullae and may complicate pneumonia, lung abscess, Tuberculosis , asthma, cystic fibrosis bronchial carcinoma. The mechanical problems caused by a pneumothorax may be considered as a) Closed pneumothorax The hole in the visceral pleura closes spontaneously. Irrespective of the cause, a pneumothorax slowly decreases in size when the air leak seals. b) Open pneumothorax .. Air leaks through the visceral pleura preventing expansion of the lung. c) Tension pneumothorax. A valvular mechanism at the site of pleural air leak allows a progressive increase in intrapleural pressure which compresses the affected lung and the mediastinal structures against the contralateral lung. This is potentially a fatal condition. Hydropneumothorax Tuberculosis Primary Tuberculosis Lymph node enlargement is unilateral in 80% of cases. hilar or paratracheal . Post-primary tuberculosis Cavitations, Consolidation miliary tuberculosis. Result from haematogenous dissemination after erosion of a vessel by a tuberculous lesion . Miliary T.B Widely disseminated micronodular shadows in miliary tuberculosis. This appearance with 2 to 5 mm well-defined and widely distributed nodular shadows is typical, but not exclusive, in miliary tuberculosis. Pneumonia: Consolidation Consolidation of the lung occurs when alveolar air has been replaced by fluid, exudate or cells. Airlessness without shrinkage occurs in all types of pneumonia, in

pulmonary oedema, when bleeding occurs into the alveoli, or when the alveoli are rilled by neoplastic cells. The radiograph shows dense homogeneous opacification Emphysema Group of disease called c.o.p.d Alveoli are destructed Smoking is the most common cause Alpha 1 antitrypsine deiciency Emhysmema is an irreversible degenerative condition Increased anterio posterio diameter of the chest(barrel chest) Hypertransradiant lung caused by severe emphysema. The diaphragm is low and flat . Differentiating the Causes of an Opacified Hemithorax Three Major Causes + 1 Atelectasisof an entire lung A large pleural effusion Pneumonia of an entire lung And a fourth cause: Post-pneumonectomyremoval of an entire lung Air Bronchogram Bronchi not visible since their walls are thin, they contain air, are surrounded by air When something of fluid density fills alveoli, air in bronchus becomes visible Pulmonary edema Blood Gastric aspirate Inflammatory Tumours Bronchogenic Carcinoma Sarcoidosis Pancoast tumor Solitary Pulmonary Nodule can be: o Malignant: Adenocarcinoma o Benign: Densely calcified nodule Deposits Mediastinum: Overview Anterior Mediastinal Mass The 4 Ts Thyroid Thymus (Thymoma) Teratoma Terrible Lymphoma (Tumour)

Free gas under diaphragm or liver in erect position. Causes: Perforation 1-peptic ulcer

2- inflammation( diverticulitis,appendicitis,toxic-megacolon necrotizing entercolitis 3- infarction 4- malignant neoplasm 5- obstruction 6- pneuomatosis coli (the cyst may rupture ) Iatrogenic 1- surgery 2- peritoneal dialysis Pneumomediastinum Pneumothorax Upper and Lower Gasstro Intestinal Tract Dysphagia Intrinsic Reflux stricture Tumours-carcinoma,lymphoma,leiomyoma Ingestioncorrosive lye,foreign body Iatrogenic-radio therapy,prollonged naso gastric intubation Candida Plummer-vinson web Skin disorders-pemphigous,epidermolysis bullosa Extrinsic Tumours-lymmph nodes,medistinal tumours Vascular-aortic aneurysm Goitre Prevertebral abscess/haematoma Neuro muscular Achalasia Sclero derma Chagas disease Myasthenia gravis Bulbar/psedobulbar palsy Psychiatric Globus hystericus Abnormal barium swallow Strictures Strictures are an important cause of dysphagia. There are four main causes; carcinoma, peptic, achalasia corrosive. In order to distinguish between these possibilities it is useful to answer the following questions: 1. Where is the stricture? 2. What is its shape? 3. How long is it? 4. Is there a soft tissue mass? Carcinomas Achalasia

Corrosive strictures Filling defects Filling defects may be caused by a tumour arising in the wall of the oesophagus, by a lesion arising from outside the oesophagus or by objects in the lumen of the oesophagus. An intramural filling defect is likely to be a leiomyoma A carcinoma Extramural lesions carcinoma of the bronchus, enlarged mediastinal lymph nodes and an aneurysm of the aorta leiomyoma There is a large filling defect in the stomach with smooth borders (outer arrows). An ulcer crater (central arrow) is present within the filling defecta characteristic feature of a leiomyoma. Dilatation of the oesophagus There are two main types obstructive and non-obstructive. / 1. Dilatation due to obstruction is associated with a visible stricture and the diagnosis becomes that of the stricture . The patient with a carcinoma usually presents with dysphagia before the oesophagus becomes very dilated. On the other hand a markedly dilated oesophagus indicates a very long-standing condition, usually achalasia or occasionally a benign stricture. 2. Dilatation without obstruction occurs in scleroderma. The disease involves the oesophageal muscle resulting in dilatation of the oesophagus, which resembles an inert tube with no peristaltic movement so that barium does not flow from the oesophagus into the stomach unless the patient stands upright. Varices Oesophageal varices. Tortuous worm-like filling defects are seen in the lower half of the oesophagus. Oesophageal web There is a shelf-like indentation (arrow) from the anterior wall of the upper oesophagus. Diverticula Diverticula are saccular outpouchings which are often seen as chance findings in the intrathoracic portion of the oesophagus. One type of diverticulum, the pharyngeal pouch or Zenker's diverticulum, is important as it may give rise to symptoms due to retention of food and pressure upon the oesophagus. Barium meal Barium meal is acontrast examination of the stomach and dudenoum Indication Dyspepsia Upper abdominal mass

 Gastro intestinal haemorrhage Gastic out let obstruction Abnormal barium meal Gastric ulcers Depending on the projection ulcers may be seen either en face as a collection of barium occupying the ulcer crater, or in profile as a projection from the lumen of the stomach Gastric ulcers may be benign or malignant. Benign ulcer ) In profile the ulcer (arrow) projects from the lesser curve of the stomach Malignant (Carcinoma) There is a large filling defect in the antrum and body of the stomach with overhanging edges (arrows). Leiomyoma There is a large filling defect in the stomach with smooth borders (outer arrows). An ulcer crater (central arrow) is present within the filling defecta characteristic feature of a leiomyoma. Bezoar Masses of hair in the stomach have caused irregular filling*of the stomach with barium. Narrowing of the stomach Linitis plastica . The stomach is narrowed by an extensive carcinoma converting it to a rigid tube with obliteration of mucosal folds. Displacement of the stomach by a large pancreatic mass (a pseudocyst) THE SMALL INTESTINE Table 1. Distinguishing Features of Small and Large Bowel. Small Bowel Location Mucosal Folds Diameter Fecal Content Central Continuous (Plicae Circulares) < 3cm Rarely Colon Picture Frame Interrupted (Haustra) < 6 cm (Cecum < 9 cm) Usually

Narrowing . The only normal narrowings are those caused by peristaltic waves. They are smooth, concentric and transient with normal mucosal folds traversing them and normal bowel proximally. The common causes of strictures are: Crohn's disease, Tuberculosis and malignant lymphoma Strictures do not contain normal mucosal folds and usually result in dilatation of the bowel proximally. Narrowing. There is a long irregular stricture (arrows) in the terminal ileum due to Crohn's disease. There is an abnormal mucosal pattern in the

remainder of the terminal ileum. Note the contracted caecumanother feature of the disease Ulceration. The outline of the small bowel should be smooth apart from the indentation caused by normal mucosal folds. Ulcers appear as spikes projecting outwards which may be shallow or deep Ulceration is seen in Crohn's disease, tuberculosis and lymphoma. When there is a combination of fine ulceration and mucosal oedema a cobblestone appearance may be seen. Crohns disease Mainly affects the terminal ileum Affects any age [young adults] Males more than females Etiology is obscure Sites of affection Esophagus very rare Stomach and duodenum 0.5-7% Colon and anal canal Small intestine specially the terminal ileum 55% Complications Perforation ulcers penetrate the intestinal wall Slow peritoneal adhesions blind fistula/ abscess Rapid free intraperitoneal air 2-3% of cases Tuberculosis Tuberculosis is indistinguishable from Crohn's disease on barium examination. It commonly affects the ileocaecal regioion Lymphoma The infiltration in the wall of the bowel with lymphoma gives an appearance that is often extremely difficult, to distinguish from Crohn's disease. Additional features to look for that may help differentiate the two conditions are small mucosal filling defects due to tumour nodules (, and displacement of loops caused by enlarged lymph nodes. Enlargement of the liver and spleen may also be present. Worm infestation Roundworms (Ascaris) are the commonly encountered worms that are large enough to be seen as filling defects in the lumen of the bowel (they may grow up to 35 cm long) . The worms themselves may ingest the barium to have their own barium meal and barium may be seen in their digestive tracts. THE LARGE INTESTINE The standard radiological examination of the large intestine is the barium enema. Barium is run into the colon under gravity through a tube inserted into the rectum. Films are taken in various projections so that all the loops of colon are included. In the 'single contrast method' the whole colon is distended with barium. When a 'double contrast technique' is used only part of the colon is filled with barium and air is then blown in to push the barium around the colon with the result that the colon is distended with air and the mucosa coated with barium Strictures. The main causes of stricture formation are: (a) Carcinoma.

 (b) Diverticular disease. (c) Crohn's disease. (d) Ischaemic colitis. (e) Rarer causes include tuberculosis, lymphogranuloma venereum, amoebiasis and radiation fibrosis. Stricture. A short circumferential narrowing is seen in the sigmoid colon (arrow) due to a carcinoma. Ulcerative colitis Ulcerative colitis is a disease of unknown aetiology characterised by inflammation and ulceration of the colon. The disease always involves the rectum. When more extensive it extends in continuity around the colon sometimes affecting the whole colon. The cardinal radiological sign is widespread ulceration . The ulcers are usually shallow but in severe cases may be quite deep. In all but the milder cases there is loss of the normal colonic haustra in the affected portions of the colon. Strictures are rare and when present are likely to be due to carcinoma; the ulcerative colitis is significantly increased. incidence of colonic carcinoma in long-standing Differences between ulcerative colitis and Crohn's disease Crohn's disease ulcerative colitis 1. Rectum involved in half the cases /. Rectum involved in all the cases 2. Colon may be affected segmentally 2. Colon always affected continuously 3. Ulcers deep 3. Ulcers shallow 4. Some cases show asymmetrical loss of 4. Symmetrical loss of haustra is the rule haustrae 5. Fistulae are a feature 5. Fistulae very rarely occur 6. Anal or perianal lesions frequent 6. Anal or perianal lesions uncommon 7. Small bowel involvement common 7. Small bowel normaldilatation of the particularly of the terminal ileum with narrowing terminal ileum may be seen in the region of the ileocaecal valve Diverticulosis Diverticulosis means that multipule diverticula are present Colonic diverticla are acommon cause of alower gastro intestinal bleeding Diverticulitis is an inflamatory process caused by stagnation of inspissated feces within adiverticulum The sigmoid colon is the most commonly affected p0rtion of bowel Volvulus Torsion of the colon can only occur in those parts having along, freely mobile mesentery.Sigmoid and the caecum therefor is the more common site. Caecal volvulus :- Can only occur when there is a degree of malrotation and the caecum and ascending colon are on a mesentery. In comparison with the sigmoid it usually occur in the young individuals . Sigmoidal volvulus is the classical volvulus .occurring mostly in the old age or mentally retarded individuals .

 The usual mechanism is twisting of the sigmoid around the mesenteric axis. U-shaped loop. Liver overlap sign. Lt flank overlap sign. Pelvic overlap sign. Inferior convergence plain films radiological feature . Pneumoperitonum :The presence of intraperitoneal air in acutely ill patient is an important radiological signs that usually indicate bowel perforation. Inflammatory conditions Acute appendicitis. The commonest acute abdominal condition. Investigation are not substitute for good clinical history. There is no specific plain film signs of acute appendicitis.. UlS & CT shows great potential to improve diagnostic accuracy. Graded compression U/S is a well- documented technique . U/S signs : 1/ Blind ending tubular structure. 2/ Non-compressible. 3/ Diameter 7mm or greater. 4 No peristalsis.5/ high echogensity surrounding fat.6/ edema of the caecal pole. 7/ maximum tenderness over the appendix. Acute Cholecystits Almost all cases of acute cholecystitis are associated with stones. Most are caused by obstruction of the cystic duct. Gall stones , Size of the GB, and the wall thickening can all be determined clearly by U/S technique . Acute pancreatitis The pathological changes of acute pancreatitis include 1/edema . 2/, hemorrhage. 3/ infarction . 4/ fat necrosis. Liver Biliary System and Pancreas GI Tract: Solid Organs Difficult to see on plain films Best imaged by CT Ultrasound Contrast studies ERCP, PTC MRI Nuclear Medicine scan Physiologic exams - HIDA, Liver/splen scan BILIARY SYSTEM METHODS OF INVESTIGATIONS: 1. Plain X-Ray. 2. Ultrasound. 3. CT Scan. 4. ERCP. 5. PTC.

6. 7. 8. 9.

T-tube Cholangiogram. Intra-Operative Cholangiogram. Oral Cholecystogram (Historical). Nuclear Scan.

Ultrasonography noninvasive, inexpensive, widely available, it should still be used first whenever feasible The more invasive and expensive techniques such as CT and MRI should be reserved for those cases in which ultrasound has not been able to provide an answer to the clinical questions FRIENDS & ENEMIES OF ULTRASOUND Friends Enemies Asthenic (skinny patients) Gas Fasting: Empty stomach Fat (pancreas) Adequate window: Full bladder (for Post uterus) operative pts. U/S terms Echogenicity Iso echoic same echogenicity Un echoic echo-free =without echo=black=fluid Hypo echoic =less echoes =decreased echogenicity Hyper echoic =more echoes =increased echogenicity Acoustic shadow Fatty infiltration Fatty infiltration of the liver is charaterized By excessive depsition of fat within the Parenchymal cells of the liver Alcohol consumption is the most common Cause in adult Malnutrition is afrequent cause in children CT Scan of the Liver: 1. It demonstrates 3 dimensional planes (done in the axial plane with sagittal. And coronal reconstruction). 2. It allows better differentiation between the normal liver tissue and pathological lesions due to difference in density. Abscess: 1. The center is near fluid density. 2. The wall is thicker and more irregular than simple cyst. 3. The margin enhances, but the central portion (breakdown or degeneration) does not enhance. Cyst: 1. Well defined. 2. Rounded or oval lesions. 3. Near water attenuation. 4. No contrast enhancement of the wall or contents.

Metastases: Usually multiple, peripheral and of variable sizes (2)THE BILIARY SYSTEM AND THE PANCREAS The following investigations are discussed: Ultrasound scan. Oral cholecystography. Endoscopic retrograde cholangiopancreatography (ERCP). Percutaneous transhepatic cholangiography (PTC). Operative cholangiography. T-tube cholangiography. Hida scan. CT scan. MRI. Ultrasound Scan: This simple, non-invasive technique is the first investigation of choice in most of the biliary and pancreatic problems.

GALLBLADDER Contrast Study -Patient took oral Contrast containing Iodine -Conjugated by liver -Excreted into bile duct and gallbladder like bile Abnormalities: 1. Failure of visualization of the gall bladder is due to: a. failure of absorption of the dye due to vomiting or malabsorption b. Derangement of liver function( bilirubin more than 2mg) c. Cystic duct obstruction. d. A very pathalogical gall bladder, which can not concentrate the contrast e.g (acute or chrionic cholecystitis). 2. Radiolucent gallstone appears as filling defects inside the cholecystogram. Bile ducts: Best examined by: Ultrasound Contrast studies (PTC, ERCP) CT MRI Endioscopic retrograde cholangiopancreaticography (ERCP) ERCP is very valuable in the diagnosis of the following problems: 1: Diagnosis of lesions involving the lower end of the CBD as carcinoma of the head of pancreas or ampulla of Vater. 2. Diagnosis of calculi in CBD. 3. Detection of operative injuries of the bile duct. 4. Visualization of the pancreatic duct in patients with chronic pancreatiteis and pancreatic pseudo cyst. Complications sometimes may follow ERCP: Pancreatitis. Cholangitis especially when there is unrelieved obstruction in the CBD Biliary leakage and haemorrhage.

 Damage of the papilla. Causes of failure: 1. Papillary stenosis. 2. Papillary tumors. 3. Duodenal diverticulum.. 4. After gastrectomy. Percutaneous Transhepatic Cholangioraphy (PTC) : Technique: A needle placed through the skin Using ultrasound guidance bile ducts found Dye injected through needle to visualize bile ducts. Complications of PTC: Bleeding. Biliary Leakage or subphrenic abscess. Cholangitis. Septicaemia and endotoxic Shock. Operative Cholangiography: This investigation is performed during cholecystectomy operation to detect any stone in the CBD. A tiny cannula is introduced through the cystic duct into the CBD. 4 mls of diluted contrast are injected and a film is taken, then another 4 mls of the contrast injected and another film is taken. T -tube cholangiography: After choledocholithotomy a T-tube is inserted into the CBD. On the 7th 10th post operative day, T -tube cholangiography is performed by putting a clamp on the tube and injection of contrast material through the tube taking care not to inject air. Cholangiogram A study of bile ducts (cholangiogram) Technique: Water-soluble contrast was injected into the biliary system via a tube left in place following removal of the gallbladder (cholecystectomy) CT scan of the pancreas: Acute pancreatitis: Diffuse enlargement of the pancreas. Irregular outline due to extension of inflammation to the surrounding fat. Chronic pancreatitis: Calcification of pancreatic tissue. Atrophy of glandular tissue. Dilatation of the pancreatic duct. Pancreatic carcinoma: Irregular focal enlargement. Pancreatic duct and CBD are dilated in 50% of cases. Obliteration of peripancreatic fat planes denotes extraglandular extension. CT demonstrates the presence of lymphatic or hepatic metastases.