chest x ray

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Slide 1 :

Chest & Abdominal X-ray Interpretation Lt Col NK Jain Gd Spl (Radiology) MH Jabalpur

Slide 2 :

The Chest X-Ray

Slide 3 :

Techniques - Projection P-A (relation of x-ray beam to patient)

Slide 4 :

Techniques - Projection (continued) A-P Supine/Erect

Slide 5 :

Techniques - Projection (continued) Lateral

Slide 6 :

Techniques - Projection (continued) Lateral Decubitus

Slide 7 :

Technical Factors Centering Penetration Inspiration

Slide 8 :

Rotation

Slide 9 :

Rotation (continued)

Slide 10 :

Penetration

Slide 11 :

Inspiration/Expiration

Slide 12 :

Densities The big two densities are: (1) WHITE - Bone (2) BLACK - Air The others are: (3) DARK GREY- Fat (4) GREY- Soft tissue/water And if anything Man-made is on the film, it is: (5) BRIGHT WHITE - Man-made

Slide 13 :

Systematic Approach Bony Framework Soft Tissues Lung Fields and Hila Diaphragm and Pleural Spaces Mediastinum and Heart Abdomen and Neck

Slide 14 :

Systematic Approach Bony Fragments Ribs Sternum Spine Shoulder girdle Clavicles

Slide 15 :

Systematic Approach Soft Tissues Breast shadows Supraclavicular areas Axillae Tissues along side of breasts

Slide 16 :

Systematic Approach Lung Fields and Hila Hilum Pulmonary arteries Pulmonary veins Lungs Linear and fine nodular shadows of pulmonary vessels Blood vessels 40% obscured by other tissue

Slide 17 :

Systematic Approach Diaphragm and Pleural Surfaces Diaphragm Dome-shaped Costophrenic angles Normal pleura is not visible Interlobar fissures

Slide 18 :

Systematic Approach Mediastinum and Heart Heart size on PA Right side Inferior vena cava Right atrium Ascending aorta Superior vena cava

Slide 19 :

Systematic Approach Mediastinum and Heart Left side Left ventricle Left atrium Pulmonary artery Aortic arch Subclavian artery and vein

Slide 20 :

Heart Size:

Slide 21 :

Heart Size of heart Size of individual chambers of heart Size of pulmonary vessels Evidence of stents, clips, wires and valves Outline of aorta and IVC and SVC

Slide 22 :

Systematic Approach Abdomen and Neck Abdomen Gastric bubble Air under diaphragm Neck Soft tissue mass Air bronchogram

Slide 23 :

Anatomy

Slide 24 :

Lobes Right upper lobe:

Slide 25 :

Lobes (continued) Right middle lobe:

Slide 26 :

Lobes (continued) Right lower lobe:

Slide 27 :

Lobes (continued) Left lower lobe:

Slide 28 :

Lobes (continued) Left upper lobe with Lingula:

Slide 29 :

Lobes (continued) Lingula:

Slide 30 :

Lobes (continued) Left upper lobe - upper division:

Slide 31 :

Pleura Layers: Visceral Parietal Angles: 1. Cardiophrenic 2. Costophrenic

Slide 32 :

Slide 33 :

Hilum Made of: 1. Pulmonary Art.+Veins 2. The Bronchi Left Hilum higher (max 1-2.5 cm) Identical: size, shape, density

Slide 34 :

Hilum

Slide 35 :

The Normal Lateral Chest X-ray Lateral View: Oblique fissure Horizontal fissure Thoracic spine and retrocardiac space Retrosternal space

Slide 36 :

Lateral CXR (continued)

Slide 37 :

Lateral CXR (continued)

Slide 38 :

Lateral CXR (continued)

Slide 39 :

Identify the lesion ? localise the lesion ? describe the lesion ? give DD Never stop looking, carry on with your systematic approach!!

Slide 40 :

Pathology

Slide 41 :

The Silhouette Sign An intra-thoracic radio-opacity, if in anatomic contact with a border of heart or aorta, will obscure that border. An intra-thoracic lesion not anatomically contiguous with a border or a normal structure will not obliterate that border.

Slide 42 :

Consolidation Lobar consolidation: Alveolar space filled with inflammatory exudate Interstitium and architecture remain intact The airway is patent Radiologically: A density corresponding to a segment or lobe Airbronchogram, and No significant loss of lung volume

Slide 43 :

Atelectasis Loss of air Obstructive atelectasis: No ventilation to the lobe beyond obstruction Radiologically: Density corresponding to a segment or lobe Significant loss of volume Compensatory hyperinflation of normal lungs

Slide 44 :

Practice Time

Slide 45 :

Slide 46 :

Right Middle and Left Upper Lobe Pneumonia

Slide 47 :

Slide 48 :

Pseudotumor: fluid has filled the minor fissure creating a density that resembles a tumor. Also seen is right pleural effusion

Slide 49 :

Slide 50 :

CHF: accentuated interstitial markings, Kerly lines, and an enlarged heart. Normally indistinct upper lobe vessels are prominent but are also masked by interstitial edema.

Slide 51 :

Slide 52 :

Chest wall lesion: arising off the chest wall and not the lung

Slide 53 :

Slide 54 :

Pleural effusion: Note loss of left hemidiaphragm. Fluid drained via thoracentesis

Slide 55 :

Slide 56 :

Lung Mass

Slide 57 :

Slide 58 :

Small Pneumothorax: LUL

Slide 59 :

Slide 60 :

Metastatic Lung Cancer: multiple nodules seen

Slide 61 :

Slide 62 :

Perihilar mass: Hodgkin’s disease

Slide 63 :

Slide 64 :

Widened Mediastinum: Aortic Dissection

Slide 65 :

Slide 66 :

Pulmonary artery stenosis with cardiomegally likely secondary to stenosis.

Slide 67 :

RUL Pneumonia

Slide 68 :

Slide 69 :

Pneumothorax

Slide 70 :

RUL collapse

Slide 71 :

Air under the diaphragm

Slide 72 :

Emphysema

Slide 73 :

Cavitating lesion

Slide 74 :

Hiatus hernia

Slide 75 :

Miliary shadowing

Slide 76 :

Chest Tube, NG Tube, Pulm. artery cath

Slide 77 :

Abdominal Xrays

Slide 78 :

The Abdominal X ray Not used in clinical diagnosis regularly An AXR uses 50x the radiation of a plain CXR Can be plain or contrast study Indications include: Suspected bowel obstruction Foreign body Stones in the renal tract To check position of stents etc .

Slide 79 :

Position of Patient Supine (lying on their back) with the plate (film) underneath them – x rays from front to back Unless otherwise labelled, the film will probably be supine Erect – may be useful if looking for fluid levels Decubitus – taken with the patient in the lateral position – may be useful to detect intraperitoneal gas Prone - patient lying on their front - occasionally used in IVUs

Slide 80 :

Interpreting the AXR Step by Step

Slide 81 :

Part 1 – Patient Details Name of patient Age Date of birth Date the radiograph was taken/time Brief info about patient

Slide 82 :

Part 2- Technical Details Type –AP/PA - supine/erect/L.decubitus/prone Orientation of film Penetration Rotation Adequate view

Slide 83 :

Part 3 – Intraluminal gas Stomach Small intestine (n= 2.5 cm) Colon (n= 5 cm) Caecum (n= 9 cm) Rectum (sometimes visible)

Slide 84 :

Clinical Findings- Obstruction

Slide 85 :

Slide 86 :

“ ERECT Note the multiple fluid levels

Slide 87 :

Part 4 – Extraluminal gas Gas under diaphragm Gas present in the peritoneum - perforation

Slide 88 :

Gas under diaphragm Gas under diaphragm

Slide 89 :

Perforation Pneumoperitoneum – Supine AXR

Slide 90 :

Part 5 – soft tissue structures Liver Spleen Pancreas Kidneys Ureters Bladder Psoas muscles

Slide 91 :

Kidney Psoas T12 vertebra Sacrum Sacroiliac joints Descending colon faeces Gas in rectum

Slide 92 :

Part 6 – Abnormal calcification Aorta Pancreas Cystic Duct Gall bladder Kidneys Ureter Bladder Urethra

Slide 93 :

Bladder calculi

Slide 94 :

Renal Stones

Slide 95 :

Ureteric Calculus

Slide 96 :

Pancreatic Calcification

Slide 97 :

Gallstones

Slide 98 :

Aorta Endovascular aortic aneurysm stent Walls of AAA

Slide 99 :

Part 7 – Look at bone structure Fractures – vertebral bodies Metastases Changes in bone density Shape

Slide 100 :

Fracture

Slide 101 :

Bone pathologies

Slide 102 :

Finally- Extra features Foreign objects ECG leads Tubes/stents Surgical clips – aid diagnosis Then summarise the findings and give possible diagnoses

Slide 103 :

Slide 104 :

Summary – Presenting Patient Details - easy Technical Details Intraluminal Gas – dilated etc. Extraluminal Gas- preforation Soft tissue Structures- “-megaly” Abnormal Calcification - stones Bony Structures Any Extra Features - objects SUMMARY

Slide 105 :

NORMAL Hepatomegaly

Slide 106 :

Dilated Small Bowel

Slide 107 :

Stag Horn Calculus

Slide 108 :

Pneumobilia

Slide 109 :

Toxic Megacolon

Slide 110 :

Volvulus

Slide 111 :

Pancreatic Calcification

Slide 112 :

Gall Stones

Slide 113 :

Small Bowel Obstruction

Slide 114 :

Vesical Calculus

Slide 115 :

Renal Calculi

Slide 116 :

Thank You

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