RAdiology- Cardiac Imaging & abdominal imaging (57)

Plain films – CXR,
Echocardiography (U/S),
Duplex U/S of large vessels,
Nuclear medicine scan (MUGA),
Angiography,
CT and MRI are not considered first line imaging techniques

-Valvular disease
-Cardiomyopathy
-Congenital heart disease
-Pericardial effusion
-Mass lesions

symetrical enlargement, particular chanbers

-echocardiogram or MUGA scan.
-Normal ejection fraction is above 50% in older patients.
-Angiogram may be indicated if the EF is less than 35%.

Film shows filling-in of retrosternal space caused by r atrial and r ventricular enlargement

commonly caused by mitral stenosis and is seen as four bumps on the left cardiac border.

Usually normal or slightly enlarged cardio-thoracic ratio
Convexity of left heart border 2° to enlarged atrial appendage–only in rheumatic heart disease
Small aortic knob from decreased cardiac output
Double density of left atrial enlargement

Transesophageal echocardiography: bulky vegetation on the anterior mitral leaflet.
mitral valve with masses

causes an acute marked enlargement with the heart appearing pendulous and very wide at the base – “water bag appearance.”
-Pericardial effusions must be greater than 250ml to be seen on CXR.
-The procedure of choice for further evaluation is an echocardiogram

include pulmonary artery enlargement, right atrial and right ventricular enlargement.
-Film shows filling-in of retrosternal space and increased size of the pulmonary artery.
*heart size at upper limits of normal and increased pulmonary vascularity

dyspnea, tachypnea, pleuritic chest pain, rales, fever, tachycardia and hemoptysis.
35% of patients have signs of phlebitis but 65% of patients do NOT.
**CXR is not specific – may have small pleural effusion, atelectasis, infiltrate or elevated hemidiaphragm.

small pleural effusion, atelectasis, an infiltrate or elevated hemidiaphragm.

wedge-shaped pleural based infiltrate
with PE

dilation of the pulmonary arteries proximal to the embolus and the collapse of the distal vasculature creating the appearance of a sharp cut off

The patient’s ventilation-perfusion (V-Q) lung scan demonstrated perfusion defects involving the entirety of all three segments of the upper lobe of the right lung.

spiral CT with contrast

PE

-Widened mediastinum of more than 8 cm near the aortic arch.
-Deviation of the trachea to the right.
-Apical pleural density on left due to bleeding above the apical lung.

separation of the layers of the aortic walls allowing blood to flow between the layers of the aortic wall. Often associated with aortic aneurysm.
-Dilated aorta
-Widened mediastinum
-Cardiomegaly
-Double contour of aortic arch
-Up to 25% of CXR’s may be normal

-Dilation of the aorta with or without dissection of the aortic wall.
-Can be thoracic or abdominal.
-Widening of aorta greater than 5 cm is at risk for rupture.
-CT scan with contrast is the test of choice

thoracic

Initial study of choice is the duplex ultrasound of the thigh and inguinal region.
Second line study is a contrast venogram – contrast is injected into the distal venous system from the dorsum of the foot.

Duplex u/s can evaluate anatomy plus direction and magnitude of flow.

Used for viewing motion of the heart, diaphragm, or abdomen
real time images on monitor

Most useful in evaluating the lungs, kidneys, and bony structures
-Indications – evaluation of internal organs, injuries, masses, and suspected tumors
-images are slices of area scanned
-CT or PET

Contrast agents are often used with plain films to highlight adjacent structures of similar densities
-evaluation of GI tract, urinary system or blood vessels.

gas pattern, soft tissue and bony structure

gas patterns and air fluid levels

for free air under the diaphragm
*Possible to see as little as 3-4 cc of air

inflation of the peritoneal cavity with carbon dioxide gas to prevent injury to abdominal structures during laparoscopic surgery

esophagus

stomach/duodemum

details of small bowl

colon

x-ray exam of your stomach and the upper section of the small intestine. To be able to see these structures on an x-ray they must be outlined with barium. Barium is a liquid that is swallowed and appears white on a x-ray picture.

Noncontrast CT scan shows diffuse nodularity of the hepatic contour associated with enlargement of the lateral segment (LS) of the left hepatic lobe and caudate lobe (C). Note the interposition of the colon (arrow) between the liver and lateral abdominal wall. RL, right lobe.

from the lateral view can see the triangle of the middle lobe

The most common cause is a perforated abdominal viscus, generally a perforated peptic ulcer, although any part of the bowel may perforate from a benign ulcer, tumor or abdominal trauma

should be 1 cm about carina

et tube 1 cm above

-The nasogastric (NG) tube should be seen curving to the left in the stomach past the gastro-esophageal junction.
-On lateral view it is behind the trachea and the heart.

1. Pt hx
2.Type film
3.Postion pt
4.Inspirtory effort
5.identify struct/abnorm
6.Blind spots
7.Check old film
8.Decide on findings/differential

normal structures

ultrasound

the dilation (swelling) of one or both kidneys

Used to evaluate most of the tubular GI tract except the small bowel
*Provides direct visualization of tissue
Allows for biopsy, cauterization or injection of contrast/dye

– Examine hepatobiliary syste
-presence of stones, tumors, or narrowing in the biliary and pancreatic ducts.

Black tarry stool, from upper gi tract

upper endoscopy, if melena bleeding, use colonoscopy if bright red. if not found nuclear medicine test or capsule endoscopy.

are of two types depending on which abdominal view you are using.
* LEFT LATERAL DECUBITUS VIEW, the air rises and is trapped between the lateral margin of the right lobe of liver and the diaphragm. *Sometimes depending how big the patient is, the air may rise along the right lower quadrant around the Cecum (region of the iliac wing) especially if the pelvic bones are large in women.

Localized collection of pus – pus forming a pocket

bowel perforation, ruptured ectopic pregnancy, ruptured ovarian cyst, aneurysm, ischemic bowel

appendicitis, cholecystitis, bowel obstruction

an abnormally widened appendix with thickened walls (arrow) and incomplete contrast filling. Linear soft tissue structures in fatty tissue (arrowheads) indicating periappendiceal inflammation.

can see the air under diaphragm

grown into the pelvis, but pelvic masses grow into abdomen

-common and may or may not be medically significant
-location of the calcifications will determine their etiology
*RUQ calcifications are usually kidney stones or gallstones; U/S will distinguish between the two
*LUQ calcifications are usually related to the spleen
*Pancreatic calcifications are horizontal and at the L1-L2 level

Ct is more sensitive for these

benign

– stone in the appendix
RLQ pain + appendicolith = appendicitis
*Very high suspicion for appendicitis if patient has pain and appendicolith

*calcifications within the pelvic venous system
*1 cm or less in diameter – *may have a lucent center
No clinical significance

*(leiomyomas) calcification of uterine fibroids
*Located in the pelvis
*This AP radiograph of the pelvis reveals a large calcification which represents calcified uterine leiomyomata

secondary to benign prostatic hypertrophy

End of tube should be in the distal duodenum or jejunum and pass from the left through the duodenum on the right back to the left into the jejunum

= difficulty swallowing or sensation of food sticking
*Most common cause is hiatal hernia with GERD
*Other causes include dysmotility, strictures or central nervous system pathology

= pain with swallowing
Most common cause is infection or esophagitis

*Mild-Mod symptoms = trial of medication is first step – no need for imaging
*If symptoms persist or worsen next step is endoscopy – (EGD) esophagogastroduodenoscopy
*Other studies include an intraesophageal PH probe and/or a nuclear medicine study for reflux
*Severe dysphagia or odynophagia are indications for an EGD
-A barium swallow or UGI study may be done first if the wait for an EGD is prolonged

upper portion of the stomach protruding through the diaphragm (hiatal hernia).

Air fluid level in cardiac silouette
-see the line going across the heart, that is the line

Cells in the irritated part of the esophagus may change and begin to resemble the cells that line the stomach.
*Sometimes the damaged lining of the esophagus becomes thick and hardened, causing strictures.

* common cause of food getting stuck at certain level
*Middle and distal strictures are often due to scarring from GERD or a tumor
*All strictures need to be evaluated by EGD and biopsied to rule out a malignancy
*Can also be dilated during the EGD

from gerd, benign

Barium swallow demonstrating stricture due to cancer.

the gastroesophageal sphincter fails to relax and the esophagus becomes massively dilated and loses it’s elasticity
*usually no gerd
*Note the dilated and tortuous esophagus (oe) with narrowing at the cardia (c) and the esogastric junction, and normal stomach (st)

*collagen vascular disease that affects smooth muscle
*Esophagus dilates moderately and loses all contractions
*May have symptoms of GERD

*Most causes of esophagitis (including Barrett’s) not well visualized by contrast studies
*Candida albicans esophagitis can occur in immuno-compromised patients and can be seen by contrast studies
*Best evaluated by EGD

*spontaneous perforation of the esophagus due to pressure changes
*Severe epigastric pain and dyspnea
*CXR may show pneumomediastinum, pneumothorax, or left pleural effusion

-longitudinal tear in the lesser curvature of the stomach
-Not transmural but causes hematemasis
-EGD is indicated for diagnosis and treatment

– an outpouching of the cervical esophagus that results from a weakness in the muscular wall
*Causes dysphagia

Water-soluble iodinated contrast used for GI studies if a perforation is suspected.

95% benign
-Malignant lesions have a thickened irregular wall and decrease peristalsis

a large mass indenting the lesser curve of the stomach, with a rolled edge and a large central ulcer crater.
*The normal gastric mucosal folds are absent over the mass itself

*Can be caused by obstruction by a neoplasm, diabetes, or narcotic addiction
*Enlarged stomach may be seen on plain films
*UGI or EGD can be used
*If a mass is felt on physical exam, a CT scan is indicated

Obstruction as a result of marked narrowing of the first and second parts of the duodenum due adenocarcinoma of the gallbladder

the liver is darker than usual – it is usually the same color (density) as the spleen

fluid in the abdomen due to portal hypertension – seen on plain films, CT scan or ultrasound
*Plain films only show large amounts of fluid
*U/S is cheaper than CT scan and is equally as effective.

This patient comes in with painless, abdominal swelling and a long history of drinking. Centrally there is some resonance, and laterally there is some dullness. When the patient is re-examined after rolling him to one side, the area of dullness shifts indicating fluid (ascites) in the adbomen. Because this film was taken with the patient in the supine position, the bowel gas sits centrally and there is nothing peripherally. This is a picture of massive ascites; the bowel gas floats because it is lighter. These bowel loops are literally floating on a lake of ascites in the abdominal cavity.

12-year-old boy presented with abdominal pain 16 hours after being hit from behind by a large wave while attempting to ride it to shore. The nose of his board was caught on the sandy sea floor, driving one of the base corners of the board into his upper abdomen. On examination, he was pale with a pulse of 130/minute and blood pressure of 100/60 mmHg. His abdomen was tender in the right upper quadrant with guarding. A CT scan of the abdomen revealed a large laceration to the right lobe of his liver, with a significant amount of free intraperitoneal fluid. The patient was observed closely in hospital for one week without adverse sequelae. Subsequent ultrasound scans showed resolution of his injury by four months.

Abscesses suspected anywhere in the abdomen are best imaged by CT scan with IV and GI contrast
-Biopsy is indicated to rule out malignancy

RUQ pain, fever or elevated WBC’s; + Murphy’s sign
*HIDA scan is indicated if U/S is non diagnostic and clinical suspicion remains

can cause hepatitis and pancreatitis & jaundice
-First line study is an ultrasound
Second line study is an ERCP

endoscopic retrograde cholangiopancreatography

alcoholic pancreatitis or obstruction of the common bile duct
*Diagnosed clinically-elevated amylase and lipase levels
-CT scan is the best study for evaluation of the pancreas
*ERCP is indicated if cause of -pancreatitis is unknown and to evaluate anatomy or obtain biopsies
Complications include abscess formation, pancreatic necrosis (phlegmon) and pseudocyst

pancreatitis

black blob is trauma

ct of splen hematoma

*Dilated loops of bowel > 4 cm
*”Stack of coins” pattern of dilation
*Air-fluid levels at different heights
*”String of pearls” air-fluid levels
*Strangulated hernias, appendicitis, adhesions, tumors, & inflammatory strictures

Paralytic ileus has minimal to moderate dilation
*Paralytic ileus does not have air fluid levels at different levels
* caused by vascular ischemia, inflammation, electrolyte imbalance, narcotics or after surgery

Lesions are most common in the terminal ileum and often in the colon
*Effects all layers of the mucosa with ulcerations and strictures
*Characteristic “skip lesions” seen

Cecum is the most commonly dilated region of the colon in obstruction
*Ileus should be suspected if the transverse colon is the most dilated region
*Megacolon refers to a dilated transverse colon greater than 6 cm in diameter
*There is a risk of perforation at > 9 cm

something wrong with the enteric system. massive dilation of bowel accompanied by chronic constipation
*can be caused by infectious colitis

patient presents with an eight hour history of epigastric pain that migrated down to McBernie’s Point and the WBC is elevated. The flat plate reveals a appendocolith which implies a high risk for appendicitis.

= presence of herniation of mucosa through the bowel wall (diverticula)
*rsk of perforation so no barium or endoscopy, ct or plain film

Ulcerative colitis is confined to the rectum, the colon, and sometimes the terminal ileum
*Involves the mucosa and submucosa
*Symptoms include rectal bleeding, diarrhea, and often systemic symptoms such as arthralgias
*Begins in the rectum and spreads proximally throughout the colon
*Increased risk of colon cancer – patients need frequent colonoscopy

-Abdominal pain out of proportion to the clinical findings
-Possible rectal bleeding
-“thumbprinting” on contrast studies

Signs of a malignant polyp:
> 2 cm in diameter
-No stalk
-Irregular shape or lobulated
-Multiple polyps

-“Apple core” lesion of colon cancer
-Tumor has encircled the lumen producing this appearance
*do fecal occult blood test
*may see A strictures

= twisting of the colon
*Usually involves the sigmoid colon or the cecum; Sigmoid 3 x more common
*Omega loop sign” is a massively dilated sigmoid colon – appears like an inverted U on plain films

is a massively dilated sigmoid colon – appears like an inverted U on plain films
of Volvulus (twisted colon)

measures how well your heart is pumping more accurate than echo, but doesn’t see the valve disease as well as an echo. Good for people with really irregular heart beats but not people with lung disease

what kind of scan is this?

can cause cardiomegaly

1st pic is normal the 2nd is abnormal blood flow

shows vessles.
an X-ray representation of blood vessels made after the injection of a radiopaque substance