imaging

Question 1

liver, biliary and pancreatic disease= ultrasound benefits and uses

Answer 1

noninvasive safe and cheap 
jaundiced patient
hepatomegaly or splenomegaly 
gallstones 
focal liver disease (lesions greater than 1 cm)
general parenchymal disease 
portal and hepatic vein patency 
lymph node enlargement

Question 2

colour doppler ultrasound

Answer 2

demonstrate vascularity within the lesion and the direction of portal vein blood flow

Question 3

ultrasound contrast agents (liver)

Answer 3

production of micro bubbles can detect blood flow allows the detection of vascularity and abnormal circulation within the liver nodules (specific diagnosis of hepatocellular carcinoma)

Question 4

hepatic stiffness (transient elastography)

Answer 4

volcity of the transducer beam correlates with hepatic stiffness increased stiffness is associated with worsening liver fibrosis (80% sensitivity and specificity compared to biopsy) limited to not detecting cirrhosis, and not in obese or with ascites

Question 5

useful in staging of small potentionally opera table pancreatic tumours and bile duct imaging. used to place transmural tubes to drain pancreatic and peripancreatic fluid collections

Answer 5

endoscopic ultrasound

Question 6

CT use in liver pancreas and biliary tree

Answer 6

Contrast- good for showing the arterial and venous vasculature
lesions and vascular supply of the lesions.
guidance for biopsy and also can detect calcification and used with obese patients

Question 7

MRI in Liver, BD, Pancreas

Answer 7

focal liver disease

angiography and venography of splanchnic circulation,

Question 8

Magnetic resonance cholangiopancreatography

Answer 8

This has replaced diagnostic endoscopic retrograde cholangiopancreatography. It can visualise the biliary ducts dn pancreatic ducts with high quality imaging.

Question 9

Chest X ray of the abdomen

Answer 9

rarely requested
gallstones (but only if they contain more than 10% calcium)
any sort of calcification they will show

Question 10

radionucleotide imaging

Answer 10

IODIDA scan used for acute cholecystitis

Question 11

ERCP

Answer 11

endoscopic retrograde cholangiopancreatography
technique outlines the biliary and pancreatic ducts.
Endoscope into he second part of the duodenum and cannulation of the ampulla. contrast is then injected and the patient is screened radiologically. So this is reserved for therapeutic measures such as: common bile duct stones (sphinctotomy complication acute pancreatitis)
biliary drain or stent
brachytherapy treatment for cholangiocarcinoma

Question 12

percutaneous transhepatic cholangiography

Answer 12

this goes through the skin into the liver and then contrast is inserted and then the biliary anatomy is visualised.

Question 13

liver biopsy

Answer 13

indications: 
liver disease
hepatomegaly 
jaundice severe 
cirrhosis
tumours primary and secondary 
CI: patient refused, prolonged PT greater than 3 sec 
increased bleeding risk.

Question 14

Rheumatology imaging X-rays

Answer 14

joint space narrowing, erosions in rheumatoid, calcification in the soft tissue, osteopenia (decreased bone density) or increased bone density (osteosclerosis).

1. acute back pain if it is recurrent and persistent associated with neurological signs or if worse at night and associated with fever or night sweats.
2. useful in baseline but not diagnostic in inflammatory arthritis

Question 15

Rheum US

Answer 15

detecting active synovitis in inflammatory arthritis
guide local injections
periarticular structures and soft tissue swellings

Question 16

DXA scan

Answer 16

low radiation dose scan for bone density and screening and monitoring for osteoporosis.

Question 17

MRI in rheum

Answer 17

shows bone changes and intra-articular structures in high quality detail
bone marrow oedema
articular and periarticular disease more sensitive

Question 18

CT in rheum

Answer 18

just going to show calcification little usefulness.

Question 19

arthroscopy in rheum

Answer 19

visualisation of the joints particularly the knee and the shoulder joint
repair and trimming of medic=scal tears and lose body removal.

Question 20

PET scan in rheum

Answer 20

Positron emission tomography
uses radionuclides which decay emitting positrons
F- fluorodeoyglucose indicates areas of increased glucose metabolism.
looking for tumours and large vessel vasculitis .

Question 21

renal imaging plain X ray

Answer 21

renal calcification or radiodense calculi in the kidneys renal pelvis line of the ureters or bladder.

Question 22

renal imaging= US

Answer 22

benefits of avoiding contrast and also radiation
advantages: biopsy it will provide measurements on which will be the basis of interventional procedures.
suspected renal obstruction- pelcialyceal dilatation
renal mass cystic or solid.
polycystic kidney disease ddx
doppler can detect renal artery perfusion or thrombosis (user dependent)
measure the bladder wall thickness (tumours or stones)
limits if the calculi are too small not great at visualising the ureters

Question 23

Ct in renal

Answer 23

first line therapy for suspected ureteric colic
renal masses that cannot be seen on Us
staging for renal tumours
lucent calculi that would be not seen on plain film (uric acid stones)
retroperitoneum fro tumours, fibrosis and causes of ureteric obstruction
severe renal trauma
renal arteries (by angiography)
stage bladder cancer
limits radiation and then contrast nephrotoxicity.

Question 24

MRI renal

Answer 24

renal mass
staging for prostate cancer
gadolinium for MRI angiography renal arteries

Question 25

initial imaging for a neck lump

Answer 25

ultrasound and fine needle aspiration

Question 26

imaging for dysphagia

Answer 26

1. barium swallow for looking at oesophageal motility and any obstruction. useful for a high lesion *low is barium meal if endo first in high lesion risk of injury or perforation of esophageal pouch or injury. 2. endoscopy diagnositic and therapeutic luminal and mural lesions opportunity and treat lesions (botox, stricture dilatation, stent insertion, laser coagulation) first line for low dysphagia 3. videofluroscopy- with speech therapist useful high functional dysphagia 4. manometry- this assesses pressure in the lower esophagus and peristaltic waves in the esophagus - motility disorders

Question 27

bird beak appearance on barium swallow

Answer 27

achalasia

Question 28

adenocarcinoma of the esophagus confirmed by histology what other imaging do you need for staging?

Answer 28

spiral CT chest and abdomen PET (positron emission tomography) scan endoscopic ultrasound - intramural vs transmural disease and local lymph node involvement *if PET. CT are negative for mets laparoscopy= peritoneal deposits if present relative contraindication to aggressive treatment (used if PET/ Ct negative for mets)

Question 29

ddx for a solitary coin lesion on CXR

Answer 29

``` parenchymal tumour: benign, lung ca (primary or secondary) lymph node: lymphoma granuloma: TB sarcoidosis abscess hamartoma foreign object ```

Question 30

when would you consider CT in a patient with epigastric pain?

Answer 30

if mesentaric ischemia is suspected or a AAA

Question 31

patient come in with RUQ pain what imaging are you going to do?

Answer 31

erect chest radiograph (viscus organ perforation) or it can show a widened mediastinum suggestive of a aortic dissection US of the pancreas, common bile duct and gallbladder dilatation of the common bile duct greater than 6-7 mm abdominal ultrasound indicated if signs of bowel obstruction or perforation

Question 32

Riglers sign

Answer 32

when air is present on both the lumenal and peritoneal sides of the bowel wall.

Question 33

when is an abdominal radiograph useful?

Answer 33

if you are suspecting bowel obstruction in the context of known inflammatory bowel disease (toxic megacolon) to look for a foreign body

Question 34

what could air under the diaphragm be caused by?

Answer 34

peptic ulcer perforation, or duodenal ulcer perforation bowel perforation Meckel’s diverticulum caecal diverticulum or appendicix

Question 35

what is the management of acute appendicitis?

Answer 35

``` resus nil by mouth pre-op coverage of abx appendectomy DVT prophylaxis (IM heparin) ```

Question 36

complication of appendicitis

Answer 36

appendix mass, sepsis, peritonitis, appendix abcess

Question 37

can you distinguish between an appendicial mass and abcess?

Answer 37

mass is a phlegmon and an abcess contains pus CT or ultrasound will normally be able to differentiate between the two. conservative management for mass, but not abcess needs surgical mgx

Question 38

signs of testicular torsion

Answer 38

tender testicle and scrotal erythema

Question 39

how do you confirm testicular torsion and who do you need to call?

Answer 39

``` doppler ultrasound (but call theatre before) call surgeons fast 6 hours all you have for testicular torsion. ```

Question 40

what sign can you do to distinguish testicular torsion from epididymitis?

Answer 40

elevating the effected testicle will cause relief from pain in epididymitis but not in testicular torsion (positive Phrens) if there is a positive cremasteric reflex then it is probably not testicular torsion (96%)

Question 41

process of elimination for abdominal pain in a woman who is menstrual.

Answer 41

mettelschmerz

Question 42

what causes appendicitis

Answer 42

faecolith or FB lymphoid hyperplasia of peyer’s patches or fiberous strictures at the base of the appendix or carcinoid tumour (rare) but that is why all appendix are sent for histological analysis.

Question 43

what is the neurological explanation of pain in appendicitis

Answer 43

difference between visceral and somatic pain. visceral pain = splanchnic system only senses stretch and spasm midline gut emborlogically midline organ so pain on visceral peritoneum is thought to be in midline (T10-T11) lesser splanchnic, but when the appendix enlarges then it is reaching the parietal peritoneum which has cerebral spinal inner action which can then be localised to the area of the appendix.

Question 44

imaging for acute diverticulitis

Answer 44

abdominal CT with contrast- diagnosing and planing future surgery also if suspicion of abcess or patient is seriously ill. erect chest X ray perforated viscus air under the diaphragm abdominal radiograph= only useful if bowel obstruction is suspected

Question 45

premenopausal women with LIF pain what would help you make a diagnosis?

Answer 45

transabdominal and or transnational ultrasound gynaecological cause like a ectopic pregnancy or ovarian cyst

Question 46

what should you not do in the acute phase of inflamed colon?

Answer 46

colonoscopy and double contrast enema

Question 47

management in acute phase diverticulitis

Answer 47

``` analgesia bowel rest clear fluids only IV fluids antibiotics VT prophylaxis monitor ```

Question 48

imaging for kidney stones

Answer 48

CT KUB *kidney ureter and bladder

Question 49

what finding would you expect on a radiograph image of KUB suspecting kidney stones?

Answer 49

stones hydronephrosis or hydroureter perinephric fluid CT- soft tissue rim- differentiate stones surrounded by soft tissue rather than a calcified pelvic vein tail sign- soft tissue opacity that extends from the stone like a tail - pelvic phlebolith and not ureteric stone.

Question 50

what is the psoas sign?

Answer 50

it is where one of the two psoas shadows are not visible on plain abdominal radiograph. unrealable as a patient with abdominal pathology can present with this sign like a acute pancreatitis AAA best for abdominal US if leaking abdominal CT for planning of surgery.

Question 51

what imaging would you request if there is a possible colorectal carcinoma what are the different types of endoscopes used and where can you see to?

Answer 51

proctoscopy - transparent dilator to visualise the rectum and anus rigid sigmoidoscopy - only to sigmoid flexible sigmoidoscopy- limited bowel prep with sedation splenic flexure colonoscopy - far as illeoaceal valve oesophagogastrodoudenoscopy far as duodenum upper GI bleed

Question 52

in a suspected colorectal carcinoma what radiological investigations would you consider?

Answer 52

CT colonoscopy | double contrast barium edema

Question 53

What can you visualise in a CT colonscopy?

Answer 53

The bowel is prepared and then air inflated. It shows the bowel lumen and surrounding structures like the liver and the ovaries done if patients cannot tolerate an colonscopy or a sigmoidoscopy

Question 54

double contrast barium enema. How does it work and what can you see?

Answer 54

barium edema given and then pain radiographs are taken, the lumen can be visualised but this procedure is not used frequently CT is preferred.