What kind of special imaging is MC used for the esophagus?
Barium Swallow
Esophogram for Morphology & Motility
Special imaging for Pharynx & Esophagus
- Barium
- CT Scan
What special imaging is used for the Stomach & Duodenum?
- Barium: upper GI series
- CT Scan: Neoplasia & extent of disease
Why is barium used as special imaging for stomach & duodenum?
For Upper GI Series
Esophagogastric junction to Ligamen of Treitz
What special imaging is used for the Gallbladder?
Oral Cholecystography **
Ultrasound
CT Scan
HIDA aka cholescintigraphy **
What are the contents of Oral Cholecystography for Gallbladder?
- Telopaque (contrast agen) - good for filling defects
- Cholecystagogue (fatty drink) - good for function
What is used to tract the flow of bile
Dx: bile duct obstruction, bile leakage, cholecystitis, gallstones
HIDA (hepatobiliary iminodiaceic acid scan) aka
Cholescintigraphy
What special imaging is the Gold Standard for the Pancreas?
CT Scan
It’s done first when disease is suspected
What special imaging is used for the Genitourinary Tract?
- IVP/IVU
- Excretory
- Ultrasound
- CT Scan
- Cystography
- Nuclear scans, angiography, MRI
What is IVP/IVU for Genitourinary Tract?
IVP = intravenous pyelography IVU = intravenous urography
What is Excretory for Genitourinary tract?
Pyelography / Urography
Run cannula up urethra & dump contrast
What is the most basic radiographic study of the urinary tract?
Excretory (pyelography / urography)
Special imaging for Genitointestinal tract?
- Barium: GI mucosa & lumen
- Iodinated Contrast: used with CT & MRI to show vasculature, duct systems, suspected perforation of lumen, parenchyma of solid organs
Special imaging for Colon:
- Plain film?
- CT Scan?
- Colonoscopy?
- Barium Enema?
- Plain Film: obstruction
- CT Scan: extent of disease
- Colonoscopy: lumen
- Barium Enema: obstruction, diverticulitis, inflammatory bowel disease, primary neoplasm
Special imaging for Liver & Bile Ducts
- MRI & CT: small mass lesions
- Nuclear Scinitigraphy
- Ultrasound: obstruction (not complete) or inflammatory disease of bile ducts (initial evaluation) > cholangiography or retrograde cholangiography
Special imaging for Ovaries & Uterus
- Ultrasound: usually used as the initial study
- CT scan
- MRI
- Hysterosalpingography
Special imaging for Prostate
- Ultrasound
- Retrograde urethrogram: looking for narrowing of prostate
An acute impairment of renal function after exposure to a contrast medium
- Rise in serum creatinine within 2-5 days of exposure & usually returns to normal in 7-12 days
- 1 in 75,000 contrast administrations result in death (allergic rxn)
- Greater risk with intravenous delivery
Contrast Nephropathy
What patients are at a greater risk for Contrast nephropathy?
- Pre-existing renal insufficiency
- Insulin dependent diabetic w/ secondary renal disease
- Repeated administration of contrast over short time (w/in 72hr)
- Transplant & renal dialysis pts
- Total iodine dose > 100g w/in 24 hour period
Disease that causes fibrosis of the skin & internal organs due to use of gadolinium in pts with renal insufficiency
- Gado is not safer than iodinated contrast
- Nephrotoxic
- Carries & FDA blackbox warning
- Should only be used for areas approved by FDA
- Certain types more toxic than others
- Pt w/anaphylaxis to iodine have increased risk to anaphylaxis w/gado
Nephrogenic Systemic Fibrosis (Dermopathy)
What film of the abdomen is used to diagnose bowel obstructions, gallstones & kidney stones?
KUB
Kidney Ureters Bladder
What is a KUB?
Plain film - Supine
SCOUT film — for barium enemas, bowel gas patterns, soft tissue
Ca++ may be obscured by contrast
Oblique view may be warrented
Describe Normal Bowel Gas in Stomach, Small Bowel & Large Bowel.
Stomach: almost always meganblasse
Small Bowel: 2-3 loops of nondistended bowel
Large Bowel: rectum & sigmoid (almost always
What is the normal diameter of the small bowel?
2.5 cm = 1 US quarter
What are the normal fluid levels in the stomach, small bowel, large bowel.
Stomach: almost always except supine
Small Bowel: 2-3 levels possible
Large Bowel: none normally
Supine abdomen view is looking for…
Bowel gas pattern, mass or calcification
Prone abdomen view is looking for…
Air in rectosigmoid
Upright abdomen is looking for..
Free air & air fluid levels in bowel
Upright PA Chest is looking for…
Free air, Pneumonia, Pleural effusion
May be difficult to see because they are ST structures surrounded by ST and fluid
Must be able to see an edge or notice displacement of surrounding structures
Organomegaly
How do you diagnose an enlarged liver? What is it called?
> 15 cm at midclavicular line 83%+
Hepatomegaly
How would you diagnose or recognize Hepatomegaly?
- (>15cm) at midclavicular line 83%+
- Inferior hepatic flexure
- Transverse colon below right kidney
- Liver shadow crosses right psoas margin
- Elevated diaphragm
- Riedel lobe
- Liver should not be over right ilium
Anomalous lobe by inferior tongue of liver; not continuous with shape of liver
Riedel lobe
How would you diagnose Splenomegaly?
- 12 cm longest axis
- Not project below 12 post rib
- Medial displacement of meganblasse
- Inferior displacement of splenic flexure, left kidney inf & med
Describe an adult kidney
- 10-14cm
- No more than 1.5 cm difference from side to side
- Right projects shorter than left (liver?)
Describe a child’s kidney
- Measure fr: superior endplate of L1 thru inferior endplate of L4
- Add 1cm to this measurement
- This should be the length of the right kidney
- Allow 1cm difference side to side
MC focal renal parenchymal lesions
- Rare under 30 yoa
- Found in 50% of adults over 50 yoa
- Benign & contain serous fluid
- May slowly increase or decrease in size over the years
- Will be seen on plain film if there is calcification: peripheral rim
Simple Renal Cyst
May be seen on plain film when full of urine
- Males: ______ on top
- Female: _______ on top
Urinary Bladder
Males: Round on top
Females: Flat on top
- Superior or Inferior (MC 95%) poles are connected by functioning or nonfunctioning (fibrous) tissue
- 1 in 400 births
- MC renal fusion anomaly
- MC in males
- 1/3 have other anomalies (visceral or skeletal)
- 1/3 asymptomatic
- Midline mass on xray
- More susceptible to trauma injury bc ureters pass over connecting tissue
- Often have poor drainage = stasis or urine = infection & stones
Horseshoe Kidney ***
- Both superior & inferior poles are connected
- Rare
- Same possible complication as horseshoe
- Midline soft tissue mass
Calxed (Caked) Kidney
Kidney has bumps on the surface which are a residual from development
Fetal Lobulation
- Only left kidney
- Upper lateral aspect flat due to molding of the spleen
Dromedary Hump
What kind of Obstruction:
- Post surgical adhesions (MC 60%) weeks to year later
- Neoplasms (20%)
- Hernia (10%)
- Inflammatory bowel disease (5%)
- Volvulus (3%)
- Ischemic strictures
- Foreign bodies (over size of quarter)
- Intussusceptions
- Radiation ***
Mechanical Small Bowel Obstructions
What type of obstruction:
- Colon is dilated to the point of obstruction
- Cecum is usually most dilated segment (12-15cm may rupture)
- No or very few air fluid levels
Mechanical Large Bowel Obstruction
What are the Plain film findings for bowel obstructions:
- Upright?
- Supine?
- Air Fluid levels?
Upright = multiple air fluid levels >2.5cm inverted U dilated loops
Supine = dilated loops >3cm, step ladder, stack of coins
May not see air in large bowel
Etiologies for Mechanical Large Bowel obstructions?
- Colon CA (MC)
- Diverticulitis (MC)
- Hernia
- Sigmoid or Cecal Volvulus
- Fecal Impaction
Etiologies for Small Bowel Obstruction?
- Post Surgical adhesions (MC 60%)
- Neoplasms (20%)
- Hernia (10%)
- Inflammatory bowel disease (5%)
- Volvulus (3%)
- Ischemic strictures
- Foreign bodies (over size of quarter
- Intussusceptions
- Radiation ***
List 4 common locations for Extraluminal Air
- Intraperitoneal (pneumoperitoneum)
- Retroperitoneal
- Air in bowel wall (pneumatosis intestinalis)
- Air in biliary system (pneumobility)
Etiologies:
- Perforated gastric/duodenal ulcer (MC) ***
- Perforation from carcinoma, appendicitis or diverticula
- Trauma
- Recent laparoscopy (resolves 3-10 days)
- Ostomy bags / Colostomy bags
- Peritoneal infection (gas forming organism)
- Recent surgery
Pneumoperitoneum / Intraperitoneal
Radiographic findings of Pneumoperitoneum/Intraperitoneal
- Air beneath diaphragm
- Visualization of BOTH SIDES of bowel wall (Rigler/double wall/gas relief sign) ***
- Visualization of falciform ligament (a lot of air and supine)
Air in the biliary tree due to a communication w/GI tract or skin
Etiologies:
- Surgery, Trauma, Biliary-enteric fistulas, infections, anomalous development of duct
Pneumobilia (air in bowel wall)
MC non-surgical cause of Pneumobilia
Biliary-enteric fistulas
Radiographic findings of Pneumobilia
- Tubular branching lucencies over the liver shadow
- Air in lumen of gallbladder
Obstruction of the intestine by an ectopic gallstone
- Mechanism:
Inflam > Adhesion > Duodenum > Gallstones erode thru
- MC females (7-8x)
Gallstone Ileus
- 70% of Small Bowel Obstructions (SBO) > 70yoa
- 70% obstruct ileocecal valve if > 3cm
Gallstone Ileus
All of part of the stomach herniates thru the diaphragm
Hiatal Hernia
MC type of Hiatal hernia & includes the fundus & cardia
Sliding (axial)
2nd MC type of hiatal hernia & includes the fundus
Paraesophageal
Type of hiatal hernia that includes entire stomach except pyloris
Intrathoracic
Type of hiatal hernia that includes gastroeophageal junction
Short Esophagus
Radiographic characteristics of Hiatal Hernia
frontal view & lateral view
May be fluid filled, air filled or air-fluid filled
Frontal: medial base of left lung over left side of heart
Lateral: posterior mediastinum (if larger) may cover spine
What are some DDx of Hiatal Hernia?
Pulmonary Cyst (normally not the case) Lung Abscess (pt will be sick, fever, ill) Diaphragm Tumor (no air density)
What is the diagnostic for hiatal hernias?
Barium swallow
What location aids in diagnosing & recognizing abnormal calcifications
Midline & L3/4 disc is horizontal line divider
Intraperitoneal (anterior) structures:
- Liver
- Gallbladder
- Spleen
- Stomach
- Omentum
- Bladder (portion of)
- Prostate (portion of)
- Large & small bowel (portion of)
Retroperitoneal (posterior) structures:
- Kidneys & Ureters
- Pancreas
- Ovaries & Uterus
- Rectum
- Bladder (portion)
- Prostate (portion)
- Large & small bowel (portion)
What structures lie in both Intraperitoneal (ant) & Retroperitoneal (post)?
- Bladder
- Prostate
- Large & small bowel
What are the following Patterns of Calcification:
- Rim-like?
- Linear or Track-like?
- Lamellar or Laminar?
- Cloud-like, Amorphous, Popcorn
- Cyst
- Conduit
- Concretion
- Mass
List the 5 Cyst wall (rim-like) calcifications:
- Aneurysms
- Porcelain gallbladder
- Cysts w/in kidneys, adrenals, liver, ovary, mesentery
- Some uterine fibroids
- Bladder wall (rare)
Type of calcification found in wall of a fluid filled cyst or hollow organ.
Cyst Wall (rim-like) calcification
Identify based on this description:
- A thin shell of calcification is characteristic
- Without calcification, a soft tissue mass may be seen
- Lateral Lumbar view: measurement >3.8cm requires special imaging
- AP view: usually projects to the left of the midline
- Oppenheimer Erosions (5%)
- Ultrasound is special imaging of choice
Abdominal Aortic Aneurysm
Erosions made by an aneurysm at vertebral bodies
Oppenheimer Erosions
Identify based on this description:
- Up to 10% pts > 60 yoa
- Etiologies: atherosclerosis, trauma, infection
- Looks similar to cyst
Splenic Artery Aneurysm
Identify based on this description:
- Larvae from the tape worm
- MC in Liver
- Sheep, caribou –> Dog –> Us
Hydatid / Echinococcal Cysts
echinococcus granulosis
Calcification within a channel that conveys fluid
May show flecks of calcification along the route of a vessel, parallel tracts, branching tracks or ring like opacities.
Conduit (linear or track-like) Calcification
What are the 3 MC types of Conduits
- Urinary Tract
- Vas Deferens
- Blood Vessels
Tortuous blood vessel in LUQ
Splenic Artery Calcification
Calcification in the Gallbladder wall
- chronically inflamed & thickened wall
- MC females (5:1)
- asso w/ stones, obstructed cystic duct, carcinoma (10-20%)
- ovoid or pear shaped
- refer if pt has had past gallbladder issues (first differential)
- refer if you see a cyst (2nd differential)
Porcelain Gallbladder
Calcifications that form within a duct, conduit or hollow organ
Typically formed by precipitation of calcium salts which form layers over time (pearl in oyster)
Concretion (lamellar, laminar) Calcification
What are some types of Concretion (lamellar, laminar) Calcification?
- Gallbladder (gallstones)
- Urinary tract (renal, ureteral, bladder stones)
- Kidney stones
- Staghorn Caliculi
Concretion Calcifications that are calcium carbonate, show up on plain films (10-15%), “Mercedes Benz” sign or “Crow Foot” fissures that have fluid within them.
Positive Gallstones
Concretion Calcification that are made of cholesterol, don’t show up on plain films (85-90%), Telopaque
Negative Gallstones
Concretion calcifications in old men with urinary stasis or secondary to urinary stasis — higher incidence of bladder cancer
Urinary Tract
Renal, Ureteral, Bladder Stones
Concretion Calcification that MC show up over the ilium, sometimes over the sacrum
Diverticulum/Appendix
Appendicolith, Fecalith or hard poop
Concretion Calcification of pelvic veins
Phlebolith
Concretion Calcification of the prostate would be most likely noticed where in an xray?
Tiny & right at pubic symphysis
What % of kidney stones can be seen on plain film? What are the 3 common places they can be found?
90% seen on plain film
- Trigone/Pelvis of kidney
- Where ureter crosses iliac artery
- In trigone of bladder
Concretion calcification in females with chronic kidney infections.
- Resembles deer horn
- Not a tumor
Staghorn Caliculi
What is the most common cause of pancreatic calcification (concretion calcification)?
Alcoholics
Diabetics could also be because of this
MC benign calcification in the abdomen
- seen on film
- concretion calcification
Mesenteric Lymph Node Calcification
What type of calcification is this:
- Wide range of radiographic patterns
- Typically dense center w/irregular margins
- May be amorphous (irregular shaped), curvilinear, flocculent
- Calcified mesenteric lymph nodes
- Some uterine fibroids
- Liver & Kidney malignancies
- Many benign tumors
Mass (cloud-like, amorphous, popcorn) Calcification
10% of all ovarian tumors are …
Dermoid Cysts
Mature teratomas / Cystic teratomas
- contain tissue from all 3 germ layers (meso, endo, ecto)
- arise during active reproduction years
- radiographic characteristics:
- may contain teeth (30%, bones & other tissue
- 10% have marginal calcification
- 35% contain fat (solid mass) & may be only radiographic finding
Ovarian Dermoid Cysts
Calcification:
Popcorn or cauliflower like
Mottled or speckled
Coarse marginal rim
Cyst-like rim
- You cannot determine size or number of lesions based on calcification
- If area of calcification is noted to expand on films taken weeks to months apart = suggests malignant degeneration
Leiomyoma, Uterine Fibroid, Uterine Fibroma
