Abdominal xray - imaging and interpretation ArushiGupta119
everythng about abdominal radiograph is discussed from views to obstruction to foreign body.
definetly u r not going to get bored
read and share with your peers.
Abdominal xray - imaging and interpretation ArushiGupta119
everythng about abdominal radiograph is discussed from views to obstruction to foreign body.
definetly u r not going to get bored
read and share with your peers.
Radiology ----Classical Signs in GIT Dr. Muhammad Bin Zulfiqar.
It is very difficult to learn much in the sea of radiology.
This presentation is the way to memorize classical signs in radiology.
4 BASIC TYPES OF DENSITY - air , water /soft tissues, metal /bone , fat
Two substances of the same density, in direct contact, cannot be differentiated from each other on an x-ray.
This phenomenon, the loss of the normal radiographic silhouette (contour), due to loss of difference in density is called the silhouette sign.
Radiology ----Classical Signs in GIT Dr. Muhammad Bin Zulfiqar.
It is very difficult to learn much in the sea of radiology.
This presentation is the way to memorize classical signs in radiology.
4 BASIC TYPES OF DENSITY - air , water /soft tissues, metal /bone , fat
Two substances of the same density, in direct contact, cannot be differentiated from each other on an x-ray.
This phenomenon, the loss of the normal radiographic silhouette (contour), due to loss of difference in density is called the silhouette sign.
acute abdomen conditions in radiology and their evaluation
acute pancreatitis, cholicystitis, pelvic pathology, mri evaluation , intra abdominal abcess, plain radiography evaluation of acute abdomen, vascular causes of acute abdomen, causes of acute abdomen.
social cognition domains and impairment.pptxDoha Rasheedy
Social cognition refers to a set of neurocognitive processes underlying the individuals’ ability to “make sense of others’ behavior” as a “crucial prerequisite of social interaction” The different psychological processes by which we perceive, interpret, and process social information about ourselves and others. These processes allow people to understand social behavior and respond in ways that are appropriate and beneficial Social cognitive impairments are a prominent concern, or even a core facet, of several neurodegenerative (e.g., behavioral variant of frontotemporal dementia), neuropsychiatric (e.g., schizophrenia, major depressive disorder, and bipolar disorder), and neurodevelopmental (e.g., autism spectrum disorder and attention deficit hyperactivity disorder) conditions, and often occur after acute brain damage (e.g., traumatic brain injury and stroke). Moreover, such deficits are critical predictors of functional outcomes because they affect the ability to create and maintain interpersonal relationships, thereby removing their benefits in everyday life Social cognitive disturbances might be relatively subtle and harder to detect informally. Structured social cognitive assessment is, therefore , mandated.
Basic of geriatrics and internal medicine for physiotherapistDoha Rasheedy
collection of lectures for physiotherapy undergraduate students including notes of common health issues (frailty, sarcopenia, osteoporosis, neuropsychiatric issues, constipation, metabolic syndrome and its components, orthostatic hypotension, CLD, CKD, anemia, immobilization, dizziness, falls, fatigue) and how to handle in practice.
summary of age related changes and geriatric pharmacology, safe analgesic prescription in elderly
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
1. Dr Doha Rasheedy
Doha Rasheedy
X ray abdomen
Systematically review:
1. Bowel gas
2. Soft tissues
3. Bones and abnormal calcification
https://www.youtube.com/watch?v=SWd7onzmAPo
1. Bowel gas:
Normal stomach
If the stomach contains air it may be
visible in the left upper quadrant of
the abdomen. The lowest part of
the stomach crosses the midline.
Small bowel (duodenum to terminal
ileum)
Generally the small bowel lies centrally
within the abdomen. The valvulae
conniventes (also called plicae
circulares) are thin, circular, folds of
mucosa, some of which are
circumferential and are seen on an X-
ray to pass across the full width of the
lumen.
Normal <3cm
2. Dr Doha Rasheedy
Doha Rasheedy
If perforation of the bowel is suspected then an ERECT chest X-ray must be requested. This is the most
sensitive plain radiographic study to detect the presence of free gas in the abdomen.
Normal large bowel
Peripheral position in the
abdomen (the transverse and
sigmoid colon occupy very
variable positions)
Haustra (arrowheads)
Contains faeces
3. Dr Doha Rasheedy
Doha Rasheedy
air/gas under the diaphragm - erect chest X-ray
This patient has a large volume of free gas under the diaphragm. Dark crescents have formed
separating the thin diaphragm from the liver on the right, and bowel on the left.
This patient had a perforated duodenal ulcer
Rigler's/double wall sign - diagram
Normally only the inner wall of the bowel is visible
If there is pneumoperitoneum both sides of the bowel wall may be visible
4. Dr Doha Rasheedy
Doha Rasheedy
The double wall sign (Rigler's sign) is visible
Gas separates bowel segments and forms sharp angles and triangles (asterisks)
football sign - example
2 radiographs were required to completely cover the abdomen in this large patient
A large volume of free gas has risen to the front of the peritoneal cavity resulting in a large round black
area - 'football sign'
The double wall sign (Rigler's) is also visible (arrowhead)
5. Dr Doha Rasheedy
Doha Rasheedy
Perforation:
Erect:
Free air under diaphragm
Rigler’s sign
Football sign
Supine
Falciform ligament sign
Rigler’s sign
Falciform ligament sign: Silver's sign is a sign seen with a pneumoperitoneum. It is almost never seen in
isolation. If there is enough free air to outline the falciform ligament, there is usually enough air to also
provide at least a Rigler's sign.
Falciform Ligament Sign (Free Air). White
arrows point to falciform ligament, made visible
by a large amount of free air in the peritoneal
cavity. The green arrow demonstrate both sides
of the wall of the bowel wall (Rigler's sign), a
sign of free air. The red arrow points to
increased lucency over the liver from a large
amount of free air.
Falciform Ligament Sign (Free Air). White
arrows point to falciform ligament, made visible
by a large amount of free air in the peritoneal
cavity. The green arrow demonstrate both sides
of the wall of the bowel wall (Rigler's sign), a
sign of free air. The red arrow points to
increased lucency over the liver from a large
amount of free air.
6. Dr Doha Rasheedy
Doha Rasheedy
Normal stomach bubble - erect chest X-ray
Round/ovoid - 'bubble' shape Thick upper wall Fluid level or food contents
In contrast to this, free intra-abdominal gas forms a crescent under the diaphragm, and is separated
from the lungs only by the thin membrane of the diaphragm
Chilaiditi's phenomenon
In patients who have small livers (cirrhosis),
or flattened diaphragms due to lung
hyperexpansion (emphysema), a void is
created within the upper abdomen above the
liver. This space may be filled by bowel. If this
bowel is air filled then it may mimic free gas
Chilaiditi's phenomenon - example
Gas forms a near crescent shape under the
right hemidiaphragm
There is however a thick hemidiaphragm
(partly consisting of bowel wall)
Gas can be seen to lie within bowel
Importantly, this patient with
hyperexpanded lungs, due to emphysema,
did not have acute abdominal pain
7. Dr Doha Rasheedy
Doha Rasheedy
False Rigler's/double wall sign
Gas seen on both sides of the bowel wall is contained within adjacent bowel
There are no black triangles or sharp angles on the outside of the bowel wall
False football sign - example
1 - Perirenal fat (retroperitoneal)
2 - Peritoneal fat (next to the liver)
3 - Abdominal wall fat (separating muscles of the abdominal wall)
8. Dr Doha Rasheedy
Doha Rasheedy
Small bowel obstruction – features
>3cm, multiple air fluid levels>2, some in the same loop at differe thights
Centrally located multiple dilated loops of gas filled bowel (arrowheads)
Valvulae conniventes (arrow) are visible - confirming this is small bowel
Evidence of previous surgery - note the anastomosis site (red ring) - this suggests adhesions is the
likely cause of obstruction (confirmed at surgery)
Post operative ileus
Appearances are similar to those of mechanical obstruction
There are multiple loops of gas filled bowel projected centrally over the abdomen
This patient had prolonged non-colicky abdominal pain following a Caesarian section - recovery was
spontaneous
9. Dr Doha Rasheedy
Doha Rasheedy
Small bowel obstruction – features
>3cm, multiple air fluid levels>2, some in the same loop at different hights
Features of small bowel obstruction include the central position of gas-filled and distended loops of
bowel.
The white lines passing across the full width of the bowel are 'valvulae conniventes' - these are only
found in the small bowel.
10. Dr Doha Rasheedy
Doha Rasheedy
Air–fluid levels on erect AXR—
associated with obstruction, ileus, ischaemia and gastroenteritis.
erect supine
11. Dr Doha Rasheedy
Doha Rasheedy
sentinel loop
Intra-abdominal inflammation, such as with pancreatitis, can lead to a localized ileus. This may appear as a
single loop of dilated bowel known as a 'sentinel loop
Large bowel obstruction: Dilatation of the caecum >9cm, and >6cm for the rest of the colon is considered
abnormal.
Large bowel obstruction
Here the colon is dilated down to the level of the distal descending colon. There is the impression of
soft tissue density at the level of obstruction (X). No gas is seen within the sigmoid colon.
Obstruction is not absolute in this patient as a small volume of gas has reached the rectum (arrow).
An obstructing colon carcinoma was confirmed on CT and at surgery.
12. Dr Doha Rasheedy
Doha Rasheedy
Volvulus is a specific cause of obstruction with characteristic X-ray appearances
The two commonest types of bowel twisting are sigmoid volvulus and caecal volvulus.
Sigmoid volvulus - 'coffee bean' sign
The sigmoid colon is very dilated because it is twisted at the root of its mesentery in the left iliac
fossa (LIF). The proximal large bowel is also dilated (asterisks).
The twisted loop of sigmoid colon is said to resemble a coffee bean. As in this case the loop of
dilated sigmoid colon - or 'coffee bean' - usually points upwards towards the diaphragm.
This patient is at high risk of perforation and/or bowel ischaemia
Caecal volvulus: The massively dilated caecum no longer lies in the right iliac fossa (RIF). Rather this is occupied by small bowel (red
outline). The small bowel is identified by the valvulae conniventes - mucosal folds that cross the full width of the bowel
(arrowheads). Caecal volvulus was confirmed at laparotomy
14. Dr Doha Rasheedy
Doha Rasheedy
Bowel wall inflammation
Abdominal X-rays sometimes demonstrate signs of bowel inflammation such as mucosal thickening
'thumb-printing' or a featureless colon 'lead pipe' colon.
15. Dr Doha Rasheedy
Doha Rasheedy
Toxic megacolon
The colon is very dilated in this patient with acute abdominal pain, sepsis, and a known history of ulcerative
colitis. The clinical features and X-ray appearances are consistent with toxic megacolon.
There is evidence of bowel wall oedema with 'thumbprinting', and pseudopolyps or 'mucosal islands' (red-
patches).
16. Dr Doha Rasheedy
Doha Rasheedy
The transverse colon is dilated and shows evidence of thumbprinting (black arrow)
The descending colon has a thickened featureless wall and possible pockets of intra-mural gas (white arrow). It is not
clear whether this appearance is due to intra-mural gas, or properitoneal fat interposed between the descending colon
and abdominal wall.
Patient has known Crohn's disease
Appearances are consistent with toxic megacolon
Intra-mural gas refers to abnormal gas in the wall of hollow abdominal viscus. Intra-mural gas is one of the most
serious findings on abdominal plain film requiring timely surgical intervention in adults. Linear streaks of intra-mural
gas indicate infarction of the bowel wall
17. Dr Doha Rasheedy
Doha Rasheedy
Other aberrant air:
Pneumobilia: Pneumobilia is typically seen as linear branching gas within the liver most prominent in
central large calibre ducts as the flow of bile pushes gas toward the hilum. This is in contrast to portal
venous gas where peripheral small calibre branching gas is usually seen due to the hepatopetal flow of
blood away from the hilum.
Causes
recent biliary instrumentation
o ERCP
o percutaneous or intraoperative cholangiography (small amount of gas only)
incompetent sphincter of Oddi
o sphincterotomy (~50% pneumobilia at 1 year)
o following passage of a gallstone
o scarring e.g. chronic pancreatitis
o drugs e.g. atropine
o congenital
biliary-enteric surgical anastomosis
o cholecystoenterostomy
o choledochoduodenostomy (with or without bile sump syndrome 2)
o Whipple procedure
spontaneous biliary-enteric fistula (cholecystoduodenal accounts for ~70% 3
)
o gallstone ileus
o peptic ulcer disease
o traumatic
o neoplasm, eg. cholangiocarcinoma, ampullary cancer
infection (rare)
o cholangitis
18. Dr Doha Rasheedy
Doha Rasheedy
o emphysematous cholecystitis (usually gallbladder gas only, ~20% will have gas in the
biliary tree also)
o liver abscess (if contains gas and communicates with the biliary tree)
biliary-bronchopleural fistula (rare)
Supine radiographs often
demonstrate a sword-shaped
lucency in the right paraspinal
region representing gas from the
common duct and the left hepatic
duct. This has been termed the
sabre sign and is present in ~50% of
patients with pneumobilia
19. Dr Doha Rasheedy
Doha Rasheedy
Portal venous gas: is the accumulation of gas in the portal vein and its branches. It needs to be
distinguished from pneumobilia, although this is usually not too problematic, when associated findings
are taken into account along with the pattern of gas (i.e. peripheral in portal venous gas, central in
pneumobilia).
Causes:
alterations of bowel wall
o ischaemic bowel (usually mural gas as well as mesenteric gas: mortality of 75-90%, but
gas is not an independent predictor)
o necrotic/ulcerated colorectal carcinoma (CRC)
o inflammatory bowel disease (IBD)
o perforated peptic ulcer
bowel luminal distention
o iatrogenic gastric and bowel dilatation (e.g. upper and lower endoscopic procedures,
enemas)
o paralytic ileus / mechanical bowel obstruction
o acute gastric dilatation
o barotrauma
intra-abdominal sepsis
o diverticulitis
o pelvic abscess
o cholecystitis/cholangitis
o appendicitis
unknown mechanism
o pneumatosis intestinalis
o chronic obstructive pulmonary disease (COPD)
o corticosteroid usage
20. Dr Doha Rasheedy
Doha Rasheedy
Gas forming infection in soft tissue
Air filled urinary bladder Wall: emphysematous cystitis!
An abdominal x-ray revealed gas surrounding the urine
bladder, shows curvilinear or mottled areas of increased
radiolucency in the region of the urinary bladder, separate
from more posterior rectal gas. Intraluminal gas will be seen as
an air-fluid level that changes with patient position, and, when
adjacent to the nondependent mucosal surface, may have a
cobblestone or “beaded necklace” appearance. This is thought
to reflect the irregular thickening produced by submucosal
blebs as seen at direct cystoscopy.
21. Dr Doha Rasheedy
Doha Rasheedy
Some times gas take nonspecific pattern and location:
22. Dr Doha Rasheedy
Doha Rasheedy
Soft tissues:
Abdominal X-rays provide a limited means of assessment of soft tissue structures,
Soft tissue organs visible on abdominal X-rays include the liver, spleen, kidneys, psoas muscles,
bladder (within pelvis), and lung bases (within thorax)
Liver on abdominal X-ray
The liver lies in the right upper quadrant
(RUQ) and is seen as a bland area of grey on
an abdominal X-ray.
The superior edge of the liver forms the right
hemi-diaphragm contour (arrowhead).
In this patient the breast shadow (red line)
overlies the liver, and markings of the right
lung are visible behind the liver.
The gallbladder is only rarely visible on an
abdominal X-ray. Its position is very variable.
This patient has had a cholecystectomy. The
clips mark the previous location of the
gallbladder.
Lung bases on abdominal X-ray
The lung bases, which pass behind the liver
and diaphragm in the posterior sulcus of
the thorax, may be visible on some
abdominal X-rays.
It is worth checking the lung bases as some
patients with lung pathology present with
abdominal symptoms.
If there is consolidation suspected from the
abdominal X-ray then a review of the
patient's respiratory system is necessary.
23. Dr Doha Rasheedy
Doha Rasheedy
Psoas edges on abdominal X-ray
The psoas muscles (red) arise from the transverse processes of the lumbar vertebrae (arrowheads) and
combine with the iliacus muscles. Together these powerful muscles form the iliopsoas tendon, which
attaches to the lesser trochanter of the femur (asterisk). The iliopsoas muscles are the flexors of the hip.
An abdominal X-ray often demonstrates the lateral edge of the psoas muscles as a near straight line. The
iliacus muscles are not visible, as they lie over the iliac bones of the pelvis.
Kidneys on abdominal X-ray
Natural contrast between the kidneys and the low density retroperitoneal fat that surrounds them means they are often visible on an X-
ray of the abdomen.They lie at the level of T12-L3 and lateral to the psoas muscles. The right kidney is usually slightly lower than the left
due to the position of the liver.
24. Dr Doha Rasheedy
Doha Rasheedy
Abnormal soft tissues
Spleen on abdominal X-ray: The spleen lies in the left upper quadrant immediately superior to the left
kidney
Bladder abdominal X-ray
The bladder has variable appearance
depending on how full it is. It has the
same density as other soft tissue
structures, due to its water content.
25. Dr Doha Rasheedy
Doha Rasheedy
Hepatomegaly
There is diffuse soft tissue density shadowing in the right upper quadrant due to hepatomegaly (liver
enlargement)
The enlarged liver has displaced the normal bowel downwards and to the left (arrows)
The spleen is also mildly enlarged
Massive splenomegaly
This patient with a myeloproliferative disorder has both hepatomegaly and massive splenomegaly
There is generalised increase in soft tissue density but the bowel appears pushed away by the edge of
the spleen
26. Dr Doha Rasheedy
Doha Rasheedy
Enlarged kidneys
Both kidneys are very enlarged
The bowel is not displaced because the kidneys are retroperitoneal structures
This patient had a family history of polycystic kidneys
This diagnosis was confirmed with ultrasound
Ascites
Free fluid and solid organs have similar densities
In the presence of ascites gas within bowel is located centrally
28. Dr Doha Rasheedy
Doha Rasheedy
Bones:
1.
2.
3.
4.
The lower ribs, lumbar vertebrae and sacrum are highlighted.
Bones can be used as landmarks for invisible soft tissue structures. Note the transverse
processes of the lumbar vertebrae act as landmarks for the course of the ureters (arrowheads).
The vesico-ureteric junctions (asterisks) are located at the level of the ischial spines (arrows)
.
The sacrum, coccyx, pelvic bones and proximal femora are highlighted. The sacro-iliac joint is
formed by the overlapping of the sacrum and iliac bones of the pelvis.
29. Dr Doha Rasheedy
Doha Rasheedy
4. Calcification and artifact
Ideally all jewellery that overlies anatomically important structures should be removed prior to acquiring
an X-ray
Vascular calcification and ring pessary
If seen, vascular (aorto-iliac) calcification implies a more generalised atherosclerosis.
Note the ring pessary in this elderly patient.
30. Dr Doha Rasheedy
Doha Rasheedy
Calcified structures
There are multiple incidental and asymptomatic calcified structures seen on this X-ray. The
patient is recovering from an appendicectomy (note surgical clips).
Gallstones are seen only if calcified (20% are calcified). Although they may cause symptoms they
are usually asymptomatic. If gallstone disease is suspected ultrasound examination is a more
appropriate investigation.
Costochondral calcification, calcified mesenteric lymph nodes, and phleboliths (calcified pelvic
veins) are rarely clinically significant. Occasionally additional investigations are required to
differentiate them from pathological calcium. For example phleboliths may be mistaken for
ureteric calculi. Other investigations such as intravenous urogram (IVU) or CT-KUB (CT Kidneys-
Ureters_bladder) should only be performed if there are typical clinical features of ureteric
calculi.
31. Dr Doha Rasheedy
Doha Rasheedy
Residual contrast
The large areas of very high density seen in the descending colon and rectum are caused by
residual contrast material in this patient who had a Barium enema 10 days previously.
Also note costochondral calcification, and phleboliths.
Do not mistake the tips of the transverse processes for ureteric calculi.
32. Dr Doha Rasheedy
Doha Rasheedy
Pelvic fracture and osteoarthritis
This elderly patient presented with abdominal pain with no clear history of trauma
Tenderness in the suprapubic regions was thought to be due to intra-abdominal pathology
The pubic ramus fractures was the cause of symptoms
Note the osteoarthritic appearances of the hips and lumbar spine
Bone metastases
There are numerous sclerotic
densities (white) of the vertebrae,
sacrum, pelvis and proximal
femora
This patient had a known history of
breast cancer
33. Dr Doha Rasheedy
Doha Rasheedy
Paget's disease
This patient has Paget's disease
which affects his lumbar spine
and right hemipelvis
This was an incidental finding
when looking for a cause of
abdominal pain
The typical features of Paget's are
bone expansion and coarsening of
the trabecular pattern involving
the whole of the bone(s) affected
34. Dr Doha Rasheedy
Doha Rasheedy
Ureteric stone/calculus
Look carefully for ureteric stones
which can be very subtle
Don't mistake a transverse
process for a stone
Bladder stones
Multiple well defined calcific densities are
seen within the bladder
Gallstones and mesenteric lymph node
Gallstones have a variable position
depending on the position of the
gallbladder and may be mistaken for renal
stones
Unlike renal stones they are often rounded
and cluster together
This X-ray also shows an incidental
calcified mesenteric node which may also
mimic renal stones
35. Dr Doha Rasheedy
Doha Rasheedy
Abdominal aortic aneurysm -
AAA
There is calcification of
the dilated aortic wall
Frequently only one
side of the aneurysm
is visible - as in this
image - the other
being projected over
the spine
Vascular
calcification
There is striking
calcification of the
aorta and iliac
vessels
This is a sign of
generalised
atherosclerosis
elsewhere in the
body
Appendicoliths are highly predictive of
appendicitis in patients presenting with
right iliac fossa pain
37. Dr Doha Rasheedy
Doha Rasheedy
Naso-jejunal tube
Placed for the purpose of enteral feeding
The tube passes through the stomach and forms a C-shape as it navigates the 4 parts of the
duodenum (D1-4)
The tube tip lies beyond the duodenojejunal flexure which lies on the left
Pig-tail (JJ) stent
A ureteric stent has been placed to relieve ureteric obstruction
The catheter has loops (pig-tails) at both ends which hold it in place
38. Dr Doha Rasheedy
Doha Rasheedy
Colonic stent
Large bowel obstruction can be treated with placement of a metallic colonic stent
This is often used as a temporary measure allowing a patient to recover from the effects of
obstruction prior to definitive colonic resection
Inferior vena cava (IVC) filter
An IVC filter may be used to reduce the risk of large pulmonary emboli
Most commonly used in patients who have had pulmonary embolism but for whom anticoagulation is contraindicated
IVC filters are self-expanding wire structures shaped like an umbrella
Small clots may pass between the wires of the filter but large clots are prevented from reaching the pulmonary arteries
39. Dr Doha Rasheedy
Doha Rasheedy
Foreign body - ingested
This psychiatric patient has ingested numerous radio-opaque objects
The navel jewellery is external!
40. Dr Doha Rasheedy
Doha Rasheedy
Air under Diaphragm
Plain film of the chest X-ray (A) and simple abdomen (B). After colon perforation, free air under the both
diaphragm were noted.
41. Dr Doha Rasheedy
Doha Rasheedy
free air under the patient’s diaphragm (pneumoperitoneum
42. Dr Doha Rasheedy
Doha Rasheedy
Thumb printing (bowel wall inflammation)
Findings: Mild to moderate bowel edematous walls of the tranverse colon.
Diagnosis: Crohn's Disease
Discussion:
Thumbprinting of Bowel DDx:
Inflammatory Bowel Disease - most common. i.e. Crohn's and Ulcerative Colitis
Diverticulosis or Diverticulitis
Ischemic Colitis with hemorrhage into bowel wall
Other Uncommon causes include:
Amyloidosis
Carcinoid
Angineurotic Edema
CMV colitis in AIDS
Endometriosis
HUS
Lymphoma
Parasitic Infections esp Amebiasis, Strongyloides, Schistosomiasis
Pseudomembranous Colitis
Toxic Megacolon
Typhlitis
Urticaria "colon hives"
44. Dr Doha Rasheedy
Doha Rasheedy
Thumbprinting
(red arrows) of
ascending and
transverse colon
and featureless
bowel wall
(yellow arrow) at
the left transverse
colon extending
into splenic
flexure, consistent
with wall
thickening.
45. Dr Doha Rasheedy
Doha Rasheedy
The normal diameter of the intestines on an AXR do not usually exceed:
3 cm for small bowel
6 cm for colon (large bowel)
9 cm for caecum
Arrows: bowel
wall thickening
Arrow heads:
thumb printing
46. Dr Doha Rasheedy
Doha Rasheedy
Small bowel obstruction
Small bowel obstruction can be visualised
on an AXR as dilatation of the small
bowel (>3cm). The valvulae conniventes
are much more visible and have what is
referred to as a “coiled spring
appearance”.