Inflammatory Conditions- Fetal Development In this module we will be looking at, first the evaluation of Inflammatory Conditions followed by an evaluation of Fetal Development.

Inflammatory Processes Increased vascular permeability Water and cellular infiltrations Results: Abscess, ulceration, cavitation Penetration, perforation and fistula formation Scarring, strictures The first process today I would like to speak about are inflammatory processes. The result of increased vascular permeability there is an infiltration of both water and cellular components from the bloodstream into the adjoining soft tissues. The result of this process can include under the appropriate circumstances the development of the abscess cavities ulcerations or other cavities. The development of abscess, ulceration or cavitation can ultimately lead to perforation and fistula formation or potential penetration of surfaces. The end result of these inflammatory processes include the development of scars and strictures.

Inflammatory Processes Lungs and pleura Gastrointestinal tract Soft tissues of extremities Brain A variety of inflammatory processes can be evaluated with diagnostic imaging. During this course we will talk more about inflammatory processes involving the lungs and pleural the gastrointestinal tract as well as the soft tissues of the extremity. Other areas that maybe affected include the brain which will discuss briefly as well.

Inflammatory Lung, Mediastinal and Pleural Diseases Bronchitis Acute Chronic Pneumonia Infective Chemical For now let's talk about the inflammatory processes involving the lung and mediastinum and the pleura. bronchitis can be an acute or chronic process . In general radiographically there'll be minimal abnormality identified in a patient presenting with bronchitis. This diagnosis is either made clinically or as result of endoscopic evaluation of the tracheobronchial tree. Pneumonia whether as result of infection or chemical inhalation can be more easily evaluated, demonstrated and followed with diagnostic imaging.

Inflammatory Lung, Mediastinal and Pleural Diseases Pulmonary abscess Pleuritis Empyema Lymphadenopathy A pulmonary abscess where a cavity that develops following the breakdown of tissue as a result of infection can be evaluated radiographically. Pleuritis, again a clinical diagnosis, pain and discomfort on breathing or perhaps a friction rub on evaluation by auscultation, will have very little if any imaging finding. Empyema, the presence of inflammatory fluid or pus within the pleural spaces is relatively easily demonstrated by diagnostic imaging. Similarly lymphadenopathy, if of any size within the mediastinum or the hilum will be evaluated by various imaging techniques.

Pulmonary Air Space Pattern (Consolidation or Infiltration) Alveoli filled with pus, water, blood, cells, protein Appearance- fluffy, ill defined margins Single (segmental or lobar), multiple, or diffuse distribution Rapid development Let’s talk little bit about the type of air-space abnormalities we might identify in inflammatory processes. Sometimes these changes will be referred to as consolidation or infiltration. Essentially pulmonary air space may be impacted by the presence of puss, water, blood, cells or protein within the alveoli. This would be an alveolar infiltrative pattern. The appearance of the alveolar infiltrative pattern includes a fluffy loss of air space with ill-defined margins on the radiograph this will appear as a fluffy gray or white appearance. This might involve a single segment or lobe, but it could as well involve multiple segments of lobes, either in the same hemithorax or in both hemithoraces, or may have a more diffuse distribution throughout the thorax. Pulmonary air space changes tend to develop fairly rapidly and while they may clear clinically fairly rapidly, radiographic changes may remain for considerable time.

Pulmonary Air Space Pattern (Consolidation or Infiltration) Air bronchograms –fluid filled alveoli surround air filled bronchi Butterfly shadow E.G. Pneumonia, alveolar pulmonary edema Because of the presence of fluid-filled alveoli surrounding the air filled bronchi, air bronchograms are a fairly prominent finding in many cases of pulmonary airspace disease. The more significant of these sometimes described as a butterfly shadows, can be identified in pneumonia or more frequently may be seen in an alveolar distribution of pulmonary edema in an appearance that mimics the shape of a butterfly wings in the mid or central lung zones.

LUL Lingular Pneumonia Obliterated left cardiac border Let's look at some examples of pneumonia here's an individual presenting with the left upper lobe and lingular pneumonia. This inflammatory process involving entire left upper lobe including the lingular segments. The left cardiac border is obliterated in this case. If you have had time to review the materials related to the silhouette sign, this would be an evidence of a silhouette of the left cardiac and mediastinal border.

LUL Lingular Pneumonia Lateral Consolidation anterior to the major fissure Compare to PA exam The lateral projection on the same individual demonstrates the consolidation to be anterior to the major fissure which is indicated by the white arrows compare this to the PA examination to evaluate further.

LUL Lingular Pneumonia Here, side by side, we see the left upper lobe including lingula pneumonia

LLL Pneumonia Air space disease left lower lobe Density behind heart Obliteration of left diaphragm at edge of heart Left heart border preserved Contrast the findings that we've just saw a moment ago with the findings of this examination where an individual is presenting with left lower lobe pneumonia. In this example there is airspace disease involving the left lower lobe as indicated by a density behind the heart as well as a zone of density in the left lower lung zones. When comparison is made to the opposite side we do see obliteration of the left diaphragm at the margin of the cardiac silhouette. The left heart border in this case is preserved and the involvement of the lung is in the lower lobe not the upper lobe.

LLL Pneumonia Note obliteration of the posterior portion of the left diaphragm (arrows) Right diaphragm clearly seen Here we have a lateral of the same individual. Note that the posterior portion of the diaphragm has been obliterated as indicated by the black arrows. We see some diaphragmatic border over the heart and suddenly that diaphragmatic border ends. The right diaphragm is clearly seen as indicated by the lower arrows pointing cephalad

RLL Pneumonia Density at the right lateral diaphragm Obliteration of lateral diaphragm border Here is an example of a right lower lobe pneumonia as demonstrated by the presence of a density at the right lateral diaphragmatic margin. Note obliteration of the lateral diaphragmatic border as indicated by the arrows.

RLL Pneumonia Density at the mid diaphragm Sharp margination at the major fissure (arrows) The lateral study in this individual as well demonstrates a zone of density at the mid diaphragm. In this case in a location telling us that this is in the anterior portion of the right lower lobe. Sharp margination anterior at the level of the major fissure is indicated by the black arrows.

Lung Abscess Thick walled irregular cavity RUL Fluid level representing partial evacuation of necrotic material via airway Here is an example of another individual who has had a pneumonia that has gone on to the formation of an abscess. Note the thick walled irregular cavity involving the right upper lobe. Note the air fluid level representing the partial evacuation of the necrotic material via the airway and replacement by outside air.

Lung Abscess Thick walled irregular cavity RUL Fluid level representing partial evacuation of necrotic material via airway The lateral projection of the same patient also demonstrates a thick walled cavity somewhat more anteriorly located, indicating a location anterior to the major fissure, above the minor fissure and therefore within the right upper lobe. The fluid level again represents a partial evacuation of the necrotic material via the airway.

Pulmonary Interstitial Pattern Fluid or cells in the pulmonary interstitial space e.g. Peribronchial tissue and bronchial wall, perivascular space and vessels, lymphatic structure Alveoli aerated The next inflammatory process I would like to talk about is an interstitial inflammatory pattern. An interstitial pattern is a result of fluid or cells being in the pulmonary interstitial spaces rather than within the airways themselves. For example I am referring to the peribronchial tissues and bronchial wall, perivascular space and vessels as well as the lymphatics surrounding the air spaces. The alveoli in this case remain fully aerated.

Pulmonary Interstitial Pattern Appearance: Linear, lattice-like, or multiple small nodules Examples: Cystic fibrosis, bronchiectasis, asbestosis, silicosis, and other pneumoconiosis In the pulmonary interstitial pattern we’ll note the presence of linear lattice-like parenchymal changes and the presence of multiple small nodules spread throughout the lungs. Some examples of diseases include cystic fibrosis, bronchiectasis, asbestosis, silicosis and many of the other pneumoconioses which may present with a similar pattern

Cystic Fibrosis Bronchial wall thickening Ring shadows and parallel bronchiole walls of bronchiectasis Ill-defined linear lesions Obstructive airway with low diaphragms Here is an example child with cystic fibrosis. Note evidence for bronchial wall thickening as indicated by tubular, fairly lucent structures, especially in the central lung zones, with thick walls. Note we also see ring shadows and parallel bronchial walls of bronchiectasis. Inflammatory process resulting in the breakdown of the normal muscular walls of the various bronchi. Here’s a blowup demonstrating an area where we can see the thickened walls in the presence of tubular bronchiectasis. Also note the presence of ill-defined linear lesions throughout the lungs in this individual. Because this is an obstructive airway process the diaphragms are also noted to be depressed and low in this individual

Interstitial Edema CHF Bilateral central interstitial linear lattice pattern Small nodular lesions Ill-defined enlarged hila Septal lines (Kerley’s) Multiple horizontal lines near costophrenic angles (Kerley B) Here's example of the interstitial changes are we see with congestive heart failure. There is a central interstitial linear lattice like pattern with small nodular lesions identified in the more peripheral portions of both lungs. note that the hilum of the of both sides appear somewhat enlarged and relatively ill-defined due to the presence of edema in the soft tissues. we may see septal lines of Kerly or Kerly B. lines at the peripheral lung bases in these individual . We will see these more clearly in another example. the Kerly B lines as we see the magnification view are multiple horizontal lines perpendicular to the pleura typically noted at the lung bases.

Interstitial Edema CHF Variation in another patient Cardiomegaly Pulmonary vascular changes as on prior patient In another patient we see a variation in the distribution of the changes related to congestive heart failure. Note the enlarged heart and proximal pulmonary vascular changes much like we saw on the earlier patient.

Classic Pulmonary Edema Batwing or butterfly appearance Smoke inhalation And finally an example of a patient presenting with the classic appearance of pulmonary edema or the batwing appearance or butterfly appearance sometimes referred to. This particular individual had been exposed to swallow and this was the case a small inhalation

Pleural Inflammatory Lesion Pleural effusion (hydrothorax due to exudate, transudate, blood, etc.) Pleural thickening, adhesion, calcification resulting from prior inflammatory process Usually associated with concurrent lung disease A variety of processes can affect the pleural. Among those we see pleural effusions, hydrothorax or fluid in the pleural spaces, as the result of exudates, transudate or the presence of blood and so forth . We also identify and note areas of pleural thickening, pleural effusion or perhaps calcifications as a result of prior inflammatory processes involving the pleural spaces. We usually see pleural changes associated with a concurrent lung process

Right Pleural Effusion Fluid density right base Upward concave border extends along the right lateral chest wall Some lower lung obscured Incidentally noted implanted infusion device (arrow) Here is an example the patient presenting with a right pleural effusion. A fluid density is noted at the right lung base with upward concave border extending along the right lateral chest wall. Some of the lower lung is obscured by the presence of fluid at the right lung base. Note incidentally an infusion device on the left side in this patient with breast cancer. Also note some linear densities in the right lung which may represent areas of scarring or atelectasis.

Pleural Effusion Blunting of both costophrenic angles (arrows) Loss of lower heart margins In another individual we see evidence for blunting of both costophrenic angles as well as an increased space between the apparent diaphragmatic level and the level of the gastric air bubble on the left. The lower cardiac margins are as well lost by the presence of this fluid and these are fairly large pleural effusions involving both lung bases

Pleural Effusion - Plaque Calcified plaque along both lateral chest walls (arrows) Result of Asbestos exposure Some plaque along diaphragm In addition to pleural effusions we may at times identify areas of pleural plaque or pleural scar. In this case we see calcified plaque along both lateral chest walls as indicated by the yellow arrows. This can sometimes be difficult to see, especially if there is no calcification involving this pleural plaque. There may as well in this case be some irregularities along the diaphragm likely representing other areas of deposit of pleural thickening and the presence of calcifications. This particular individual had been exposed in the distant past to asbestos. As I mentioned some plaque also seen along the diaphragm indicated by black arrow.

Pleural Effusion - Plaque Calcified plaque along both posterior chest walls (arrows) Result of asbestos exposure CT scanning can be more effective for evaluation of pleural plaques. In this case we see calcified plaque along both posterior chest at the yellow arrows. This is the result of exposure to asbestos.

Esophageal Inflammatory Disease Esophagitis commonly due to infection Bacteria Virus Fungus Gastroesophageal reflex Switching gears a bit I would like to step away from the evaluation of inflammatory processes involving the lung and move on to inflammatory processes that may affect the gastrointestinal tract. Let’s talk about the esophagus first. Esophagitis is commonly do to infection although it may be related to the ingestion of a variety of different materials. Infection can be seen by bacterial involvement or viral involvement. Fungi in the immunocompromised patient can also be opportunistic and lead to esophagitis in a patient. Gastroesophageal reflux by its nature can cause irritation of the mucosal lining of the esophagus leading to inflammatory processes or esophagitis, or could as well set the pattern for involvement by other entities.

Esophageal Inflammatory Disease Chemical substance corrosion Radiologic manifestations of different causes of esophagitis are similar No radiologic abnormalities when degree of inflammation is mild Other causes of inflammatory processes within the esophagus can include chemical substance corrosion. In general the radiographic manifestations of all the different causes of esophagitis are very similar. Please note that there will be little or no radiographic or radiologic abnormality when the degree of esophageal inflammation is mild.

Normal Esophagus Barium in esophagus Smooth indentation anterior wall upper third from the aortic arch Focal ‘ring’ distal esophagus at gastric junction Here are 2 images from a normal esophagus examination with barium in the esophagus. Note smooth indentations upon the anterior wall in the upper third from the aortic arch. Also note a focal ring distally at the esophagus gastric junction representing the area of the sphincter.

Esophageal Candidiasis Multiple oval filling defects along the esophageal mucousa Plaques of candida along the esophagus (filling defects in barium coating) A variety of pictures can be seen in the case of inflammatory processes. In the case of esophageal candidiasis we will see multiple oval filling defects involving the mucosa of the esophagus. These plaques of candida along the esophagus result of filling defects in the barium coating. Those of you who may have had a sibling or have seen a child with oral thrush or oral candidiasis may have noted the white deposits that can be seen coating the mucosal membranes of the throat and mouth. Similar findings are found in the case of esophageal candidiasis

Gastrointestinal Inflammatory Disease Mucosal changes Swelling: local or diffuse enlargement of mucosal folds Defect: ulceration Penetration, perforation and abscess formation (ULCER CRATER) Scarring: stricture Need to use contrast (barium) study to illustrate the lumen and inner wall of GI tract Let’s move on and talk about inflammatory processes that may involve the rest of the gastrointestinal tract. We can see mucosal changes. Mucosal changes are the result of local or diffuse enlargement of mucosal folds as part of the inflammatory process. We see defects involving mucosa, reflecting the presence of ulcerations, where there's been a breakdown of the mucosal surfaces. If this ulceration penetrates or perforates and perhaps leads the formation of an abscess outside of the gastrointestinal lumen. We will refer to an ulcer crater as a penetration or perforation into the adjacent soft tissues. late in the development of the inflammatory processes involving the gastrointestional tract we may see scarring or stricture. It is important that we use barium contrast or some type of contrast to illustrate the lumen and inner wall of the gastrointestinal tract.

Gastric and Duodenal Ulcers Benign ulcer: Ulcer projects beyond lumen Sharp margin, round barium dot viewed en face Edematous halo around ulcer in acute stage Mucosal folds radiate out like spokes of wheel in sub-acute or chronic stage The presentation of ulcer disease when benign will be a projection outside of the expected lumen. This may present as a sharply marginated round barium dot when viewed en face. In the acute stage there may be a edematous halo around the ulcer. In sub-acute and chronic phases, mucosal folds will radiate out from the ulcer like spokes on a wheel.

Normal Gastrointestinal Study Gas in fundus of stomach Opacification of stomach, duodenum and jejunum Peristalsis in the distal duodenal bulb Here is a normal single contrast upper GI examination with some normal gas identified within the fundus of stomach and some outline of the rugae in the stomach. Note opacification this case the stomach duodenum and a good portion of the jejunum. there is peristalsis identified in the reason of the distal duodenal bulb that's why this is not visualized quite as clearly as the other portions the gastrointestinal tract

Normal Barium Enema Single contrast exam Notice the normal haustrations Competent ileocecal valve A different patient but also a normal examination in this case a single film from a single contrast barium enema examination. Note a double density of contrast material long the distal descending colon near the junction with the sigmoid colon as a result of the presence of a single diverticula at this location. We will talk more about diverticula in another presentation. Notice that the haustra are normal. They are not circumferential but they cover a portion of the circumference of the colon at each location. The ileocecal valve is a well competent in this individual as we do not see significant reflux of contrast material into the small intestine.

Normal Barium Enema Double (air) contrast Supine image Coating of mucosa and distended with gas Appendix is filled with barium In another individual, again a normal barium enema, in this case a normal barium enema air contrast. In this technique both barium and air has been have been introduced into the colon in order to more thoroughly evaluate the mucosa. Note on the supine film coating of the mucosa and distention of gas in the transverse colon the distal descending and sigmoid colon. Also note the appendix, a curvilinear tubular structure in the right lower quadrant arising from the cecum as being normal in this particular patient.

Development And Its Anomolies I like to spend the remainder of the time in this lecture talking a bit about normal development and some of its anomalies, but primarily the normal aspect of development as we might evaluate using diagnostic imaging.

Embryo Milestones Detected by Ultrasound Gestation sac Yolk sac Embryo Placenta 4.5-5 weeks 5 weeks 5-6 weeks 8 weeks There are a variety of embryonic milestones they can be detected by ultrasound. Among these are the development of gestational sac at between 4-1/2 and 5 weeks of gestation we can routinely demonstrate the yolk sac at 5 weeks gestational age. The embryo will become apparent at somewhere between 5 and 6 weeks gestational age. The placenta can be defined and located at approximately 8 weeks gestational age

Early Gestation Longitudinal scan Anechoic structure Echogenic rim Gestational sac Cervix Sac Bladder Here, a longitudinal or sagittal view of the abdomen demonstrates the presence of a pregnant uterus with the presence of an anechoic structure within the fundus of the uterus which represents the presence of the early developing gestation. Note the echogenic rim, as well as the relative location of the cervix. Within the gestational sac we may also see a small rim-like area of echogenicity likely representing the yolk sac

Embryo Endovaginal scan, more detail, resolution Gestational sac, embryo (cursors), yolk sac Gestational age 8 weeks 4 days Here in a magnification or close ultrasound view we identify more detailed resolution as an endovaginal transducer was utilized to place transducer closer to the area of interest. In this case we see a gestational sac, the embryo as indicated by the two cursers. The yolk sac is not clearly identified in this particular image. The gestational age in this instance, approximately 8 weeks 4 days utilizing the measurement of the crown-rump length.

Yolk Sac Yolk sac indicated by two white arrows Amniotic membrane visible as faint curvilinear echoes in sac 25 Here in another view we also identify the yolk sac as indicated by the two white arrows and the letters “YS”. Note also the 2 smaller white arrows which demonstrate amniotic membrane which is visible as a faint curvilinear collection of echoes within the gestational sac.

Embryonic Heart 25 Ultrasound can be used as well to evaluate the embryonic heart. In this case we see a color Doppler evaluation showing cardiac blood flow and motion and we see a M-mode recording one of the earlier types of imaging for ultrasound of the heart where between the letter a we see a number of small peaks and this is actually a measurement looking at the motion of the chambers of the heart or the valve and from that determining the cardiac rate, which in this case was of 148 beats per minute.

12 Week Fetus Longitudinal scan Fetal head in profile Placenta located anterior In a somewhat older fetus, again a crown-rump measurement is obtained on this longitudinal scan of the fetus. Note the more echogenic material laterally representing developing placenta and in this particular image also note the profile of the fetal head including evaluation of the nose the lips and the chin region.

Fetal Head 30 Weeks Normal head axial view level of ventricles Central echogenic line = third ventricle line Ventricles(hypechoic) and choroid plexus(echogenic) Gray echogenic area=parenchyma Outer echogenic rim=calvarium At 30 weeks the views for the normal fetal head at the level of ventricles demonstrate a central echogenic line which represents the line of the opposed walls of the third ventricle. Also note that the ventricles are relatively hypoechoic structures to your left as were evaluating the current image. In the choroid plexi, are represented by a more echogenic material which appears to be draping into the ventricles on this particular instance. The relative gray echogenic area in this examination represents a presence of parenchyma. the echogenic rim noted at the periphery represents some calcification within the calvarium

Normal Fetal Chest Four chamber heart view Heart chambers labeled RA LA In the evaluation of the normal fetus involving the fetal chest, we can evaluate the heart is we see in this review, we are able to clearly define the two atria and the two ventricles and their relative relationship in the fetus and to the chest. We could evaluate for cardiac anomalies at this time. The heart chambers are labeled for your convenience on this particular instance. RV LV

Fetal Chest and Abdomen Sagittal view Rib shadows Abdominal contents Ribs Bowel Here on the sagittal view we identify normal structures including echogenic foci with posterior shadowing representing the ribs and the presence of considerable bowel within the fetal abdomen

Normal Fetal Abdomen Axial at level of kidneys Echogenic dots above represent spine(arrow) Kidneys (arrowhead) A cross-section through the abdomen at the level the kidney, in an axial plane, demonstrates both kidneys posteriorly as areas of relatively less echogenicity. The central echogenic area with shadowing represents the presence of the spine. And the various elements of the spine indicated by the arrows in this particular instance. The kidneys now demonstrated by arrow heads bilaterally

Normal Fetal Pelvis Section through level of bladder Oval hypoechoic area represents bladder (arrow) Femurs parallel linear echogenic (A) Sacrum under arrow A Fetal pelvic structures can be demonstrated. This image through the level of the fetal bladder demonstrates portions of the pubic bone as well as portions of both femurs. The oval hypoechoic zone identified centrally just posterior to the echogenic foci of the pubic bones represents the bladder. The femurs indicate indicated by letter “A” at the acetabulum are demonstrated. The femur closest to the transducer is measured on this particular example. The sacrum is beneath the arrow point at the bladder on this particular exam.

Normal Fetal Spine Sagittal view C,T, L spine Parallel row of dots represent ossification centers of pedicles and bodies Note: images not true sagittal Here are several longitudinal sections through the fetal spine. Both longitudinal and cross-sectional images are obtained through the cervical, thoracic and lumbar spine as part of a routine ultrasound examination of the pregnancy. The parallel rows of dots identified represent the ossification centers of the vertebral bodies and the pedicles. Note that these particular images are not directly in the midline.

Normal Fetal Spine Axial view * Axial view Level of cervical, thoracic and lumbar vertebrae Ossification centers triangular arrangement Body in center, pedicles lateral * At the center of each spinal canal * Here are the corresponding cross-sectional or axial images that go along with the sagittal or longitudinal images noted on the previous slides at level the cervical thoracic and lumbar vertebra. The ossification centers are identified as a triangular arrangement of echogenic foci. The body being centrally located, the pedicles being the more lateral aspect. At the center of the spinal canal I have placed an asterisk for your convenience in orientating yourself on these images. *

Fetal Femur Here is an example of the fetal femur being measured as part of the process of determing gestational age

Fetal Cord Insertion Transverse abdomen Cord insertion midline White represents doppler evaluation of blood flow in cord Fetal Abdomen In this transverse image we are able to identify the anterior abdominal wall of the fetus. The appearance of the anterior abdominal wall is of importance for several anomalies which we will discuss in another lecture. Note in this particular example we are able to identify the cord insertion at the midline as we use Doppler evaluation to determine the location of the cord and the blood. This indicated by the white arrow.

3 Vessel Cord A V On another individual we demonstrate one of the other important findings of the early gestation, that is the documented the presence of 3 cord vessels, two arteries and a vein. The presence of only a single artery leading to a higher incidence of other congenital anomalies