CHEST & ABDOMINAL X-RAYS MALIKA IBRAHIM CORE MEDICAL TRAINEE BLACKPOOL VICTORIA HOSPITAL DATA INTERPRETATION COURSE FEB 20, 2017

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1 CHEST & ABDOMINAL X-RAYS MALIKA IBRAHIM CORE MEDICAL TRAINEE BLACKPOOL VICTORIA HOSPITAL DATA INTERPRETATION COURSE FEB 20, 2017

2 1. Sample x-rays 2. Basic chest x-ray interpretation skills 3. Chest x-ray pathologies 4. Abdominal x-ray pathologies 5. Review with sample questions

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7 X-rays were discovered in 1895 by Wilhelm Conrad Röntgen ( ) who was a Professor at Wuerzburg University in Germany. Working with a cathode-ray tube in his laboratory, Roentgen observed a fluorescent glow of crystals on a table near his tube, after covering it with a black cloth. He then experimented with his wife's hand to show the effects of x-rays on the human body.

8 BASICS Penetration depends on soft tissue density (less dense= black) Views for chest x-ray (AP, PA or lateral) Views for Abdominal x-ray (Supine or erect) Quality and orientation of the x-ray Systematic interpretation

9 #1 I.D. #2 DETERMINE VIEW / PROJECTION PA- the x-rays penetrate through the back of the patient on to the film AP-the x-rays penetrate through the front of the patient on to the film. Portable x-rays are AP view

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11 AP V.S. PA AP projection images are of lower quality than PA images. The scapulae are usually not retracted laterally and they remain projected over each lung. Heart size is exaggerated (cardiothoracic ratio approximately 50%). If seen on a PA image this would be at the borderline for cardiac enlargement.

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13 #3 POSITION. UPRIGHT VS SUPINE (SICKER) #4 PENETRATION

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15 # 5 INSPIRATION Was film taken under full inspiration? -10 posterior ribs should be visible. A really good film will show anterior ribs too, there should Be 6 to qualify as a good inspiratory film.

16 #6 ORIENTATION Check for rotation thoracic spine should lie in the center of the sternum and between the clavicles. Verify Right or Left (gastric bubble)

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18 ANATOMY

19 WHAT TO EVALUATE Lungs (Air space opacity, Interstitial opacity, Nodules and masses, LN, Cysts and cavities, Lung volumes) Pleural surfaces Cardiomediastinal contours Bones and soft tissues Abdomen

20 AIR SPACE OPACIFICATION: air bronchogram : air-filled bronchus surrounded by airless lung Blood (hemorrhage) Pus (pneumonia) Water (edema) -Batwing Cells (tumor) Protein/fat: alveolar proteinosis and lipoid pneumonia

21 INTERSTITIAL OPACIFICATION: small, well-defined nodules lines interlobular septal thickening fibrosis Reticulation Differential: Idiopathic interstitial pneumonias Infections (TB, viruses) Edema Hemorrhage inflammatory lesions sarcoidosis Tumors

22 LYMPH NODES CAVITIES

23 EXUDATE VS TRANSUDATE Effusion protein/serum protein ratio greater than 0.5 Effusion lactate dehydrogenase (LDH)/serum LDH ratio greater than 0.6 LDH level greater than two-thirds the upper limit of the laboratory's reference range of serum LDH

24 A, B, C, D

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26 BONE + SOFT TISSIUE 2X2 2X3 OR MORE

27 CHECK THE HEART Size Shape Silhouette-margins should be sharp Diameter (>1/2 thoracic diameter is enlarged heart) Remember: AP views make heart appear larger than it actually is.

28 ABDOMINAL X-RAYS Ensure the whole abdomen is visible from diaphragm to pelvis. Quality of the image is often poor, with overlying bowel obscuring more posterior structures. If bowel perforation is being considered, ensure there is also an erect chest x-ray performed (as this allows free gas under the diaphragm to be identified). The small bowel s mucosal folds are called valvulae conniventes and are seen across the full width of the bowel. The large bowel wall features pouches or sacculation that protrude into the lumen that are known as haustra. do not appear to completely traverse the bowel.

29 3-6-9 RULE 3 cm for small bowel 6 cm for colon (large bowel) 9 cm for caecum

30 SMALL BOWEL OBSTRUCTION Small bowel obstruction can be visualised on an AXR as dilatation of the small bowel (>3cm). The valvulae conniventes are much more visible and have what is referred to as a coiled spring appearance. CAUSES: Adhesions Hernias Masses

31 LARGE BOWEL OBSTRUCTION Common causes are diverticular strictures and masses volvulus is a twisting of the bowel on its mesentery and most commonly occurs at the sigmoid colon or caecum. Sigmoid volvulus has a characteristic coffee bean appearance. Patients with volvulus are at high risk of bowel perforation and/or bowel ischaemia secondary to vascular compromise.

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39 THANK YOU

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