Internal Medicine Clerkship Abdominal and Chest X-Rays Internal Medicine Clerkship

Recognize this image?....... First x ray ever shot by Wilhelm Konrad Roentgen in 1896

CXR reading Before starting it is very useful to develop a sense of -what is normal Interpreting a chest x ray is a stepwise systematic study of the film When looking at CXR it is best to look at PA and lateral views...you must see abnormality in both to make sure that pathology really exists

Steps to follow Exposure – underexposed or overexposed Soft tissues – obvious masses, sub -cutaneous air, calcifications Bones – size, contour, obvious abnormalities, bone density, joints Trachea – midline or shifted Diaphragm, pleural space Heart borders, vasculature Lung fields Other – hardware (e.g. lines, tubes, etc)

CXR reading The right heart border is formed by right atrium and is obscured by the medial segment of the right middle lobe The left heart border is formed by the left ventricle and is obscured by lingular process of the LUL

Normal Chest X ray 1. Trachea. 2. Carina. 3. Right atrium. 4. Right hemi-diaphragm. 5. Aortic knob. 6. Left hilum. 7. Left ventricle. 8. Left hemi-diaphragm (with stomach bubble). 9. Retrosternal clear space. 10. Right ventricle. 11. Left hemi-diaphragm (with stomach bubble). 12. Left upper lobe bronchus.

CXR reading The trachea is midline but may be deviated to the right mildly from a tortuous aorta The costophrenic angles should be sharp on both views, except in patients with severe emphysema (can be flattened)

Bony Structures

Heart size on PA film should be less than or equal to 50% of the widest diameter of the thoracic cage

Find the Anomaly

Aorta

The aortic arch or “knob” is above the left hilum

Hilar opacities are predominantly due to PA and should be symmetric in size and density.

Vasculature

Diaphragm not equal on both sides (R>L by 1.5-2.0 cm)

What the hell is that?? A sword swallower

The minor fissure is on the right, separating the right upper lobe from the right middle lobe

Breast shadows

RUL

RML

RLL

LLL

LUL with Lingula

Lingula

LUL (without the lingula)

Find the Anomaly Left upper lobe scarring with hilar retraction with less prominent scarring in right upper lobe as well. Findings consistent with previous tuberculosis infection in an immigrant from Ecuador

Lines..

Find the Anomaly CXR demonstrates reticular nodular opacities bilaterally with small lung volumes consistent with usual interstitial pneumonitis (UIP) on pathology. Clinically, UIP is used interchangeably with idiopathic pulmonary fibrosis (IPF).

Name the condition Sarcoid—CXR of stage I (hilar lymphadenopathy without parenchymal infiltrates).

Name the condition CXR reveals diffuse, bilateral alveolar infiltrates without pleural effusions, consistent with acute respiratory distress syndrome (ARDS). Note that the patient has an endotracheal tube (red arrow) and has a central venous catheter (black arrow).

What is the Diagnosis Large right pneumothorax with near complete collapse of right lung. Pleural reflection highlighted with red arrows.

Find the Abnormality Left upper lobe mass, which biopsy revealed to be squamous cell carcinoma.

Case 1...30 year old with cough and fever

Answer...Superior RLL infiltrate

Case 2...50 year old with SOB

Answer…CHF CHF… cardiomegaly cephalization prominent hilum Angles blunted…may see pleural effusions

Congestive Heart Failure Mild congestive heart failure. Note the Kerley B lines (black arrow) and perivascular cuffing (yellow arrow) as well as the pulmonary vascular congestion (red arrow).

Case 3…25 yo with CP and SOB

Answer…Pneumothorax Symptoms...Sudden shortness of breath, dry coughs, cyanosis and pain felt in the chest, back and/or arms absence of audible breath sounds and hyperresonance to percussion of the chest wall is suggestive of the diagnosis Small pneumothoraces often are managed with no treatment other than repeat observation, Larger pneumothoraces may require chest tube placement

Case 4…44 yo with DOE

Answer…Pleural effusions Healthy individuals have less than 15 ml of fluid in each pleural space Chest films acquired in the lateral decubitus position are more sensitive than an upright, and can pick up as little as 50 ml of fluid At least 300 ml of fluid must be present before upright chest films can pick up signs of pleural effusion (e.g., blunted costophrenic angles) Once there is more than 500 ml, there are usually detectable clinical signs in the patient...decreased movement of the chest, dullness to percussion over the fluid, diminished breath sounds, decreased vocal fremitus and resonance, pleural friction rub, and egophony.

Normal AXR

Densities in AXR Black: Gas White: Calcification Grey: Soft Tissues Dark Grey: Fat Bright White: Metallic objects

Assessing the film Max normal diameter of the large bowel is 55mm Small bowel should be no more than 35mm in diameter The natural presence of gas within the bowel allows assessment of caliber - although the amount varies between individuals The cecum is not dilated unless wider than 80mm Large and small bowel may be distinguished by looking at bowel wall markings The haustra of the large bowel extend only a third of the way across the bowel from each side The valvulae conniventes of the small bowel tranverse the complete distance

Bowel Wall Markings

Extra-luminal Air Extra-luminal Gas: When a bowel is obstructed, or any other gas containing structure perforates, its contained gas becomes extra-luminal. Extra-luminal gas is never normal, but may be seen following intra-abdominal surgery or endoscopic retrograde cholangio-pancreatography (ERCP). Extra-luminal gas is seen on an erect AXR

Calcification Pancreatic Calcification Gallstones

Soft Tissue Soft tissues represent most of the contents of the abdomen and feature heavily in the AXR These tissues are poorly seen when compared to other imaging techniques such as ultrasound or CT The kidneys, spleen, liver and bladder (if filled) can be seen in addition to psoas muscle shadows and abdominal fat Rarely would action be taken on the basis of this imaging alone.

Splenomegaly

Foreign Objects Foreign Bodies represent an interesting final observation Objects that may be seen include ingested and rectal foreign bodies, items in the path of the x-ray beam such as belt buckles, dress buttons and jewelry Other objects may have been deliberately placed for example an aortic stent, an inferior vena cava filter or a suprapubic urinary catheter Sterilization clips and an intra-uterine device are common findings in women

Foreign Objects Sterilization and Surgical Clips Foreign body per rectum

Case 1... This 67 year-old women presented to the surgical ward with a distended abdomen and vomiting

Answer…SBO Multiple dilated loops of small bowel within the central abdomen, gas is not seen in the large bowel, no evidence of hernia or gallstone to suggest potential cause of the dilated loops These findings are consistent with a small bowel obstruction The three most common causes of SBO: Surgical adhesions Hernias Intraluminal masses eg, small bowel lymphoma or gallstones in gallstone ileus

Case 2... This 71 year-old gentleman visits his PCP complaining of blood in his urine. He has had a number of UTI’s in recent years

Answer…Bladder Calculi Two rounded radio-opacities measuring 4cm within the pelvis Both opacities are smooth in outline, laminated in nature, have the same density as bone and project over the bladder No other renal tract calcification Given the size of these stones and history of UTI’s these are bladder calculi Bladder calculi are more common in those with a history of: UTI’s A neurogenic bladder Bladder diverticulum

Case 3... This patient was admitted with poor renal function

Answer…Nephrocalcinosis Multiple areas of calcification project over the renal outlines bilaterally The calcification is within the medulla of the renal parenchyma The bones are normal in appearance These findings are consistent with nephrocalcinosis… Nephrocalcinosis may eventually result in acute obstructive uropathy or chronic obstructive uropathy, leading to eventual kidney failure The disorder is often discovered when symptoms of renal insufficiency/renal failure, obstructive uropathy, or urinary tract stones develop

THE END