studying

1. X-RAYS
DR.G.S.R.HAREESH

2. X-RAYS
• Plain X- Rays
• Contrast X-rays
• Barium swallow
• Barium meal
• Barium enema
• Intravenous urography
• Endoscopic retrograde cholangiopancreaticography
• T-tube cholangiogram
• Percutaneous transhepatic cholangiography

3. X-Ray Reading
1. Plain / Contrast
2. View or Orientation
3. Part of body
4. Systematic examination (ABCDE)

4. ABCDE
• A - A is for Air in the wrong place
 Look for pneumoperitoneum & pneumoretroperitoneum
 Look for gas in the biliary tree and portal vein
• B - B is for Bowel
 Look for dilated small and large bowel
 Look for a volvulus
 Look for a distended stomach
 Look for a hernia
 Look for evidence of bowel wall thickening

5. ABCDE
• C - C is for Calcification
 Look for clinically significant calcified structures such as
renal calculus, nephrocalcinosis, pancreatic calcification and
an abdominal aortic aneurysm (AAA), calcified gallstones
 Look for clinically insignificant calcified structures such as
costal cartilage calcification, phleboliths, mesenteric lymph
nodes, calcified fibroids, prostate calcification and vascular
calcification
 Look for a foetus (females)

6. ABCDE
• D - D is for Disability (bones and solid organs)
 Look at the bony skeleton for fractures and sclerotic/lytic bone
lesions
 Look at the spine for vertebral body height, alignment, pedicles and
a ‘bamboo spine’
 Look for solid organ enlargement
• E - E is for Everything else
 Look for evidence of previous surgery and other medical devices
 Look for foreign bodies
 Look at the lung bases

7. Plain X-Rays
1. Pneumoperitoneum
2. Small Bowel Obstruction
3. Sigmoid Volvulus
4. Renal Caluculus
5. Bladder Calculus
6. Pancreatic Calculi
7. Canon Ball Secondaries

8. Contrast X-rays
• Barium Swallow
• Achalasia
• Ca Esophagus
• Barium Meal
• GOO
• Barium Enema
• Ca Colon
• IVP

12. PNEUMOPERITONEUM
• Miss it and the patient may die
• Bilateral dark crescents of gas under both domes of diaphragm
• Erect posture
• Left lateral decubitus
• 1 ml of air is more than enough

15. Signs of pneumoperitoneum
• Double wall sign ( RIGLER’S sign )
• Football sign – centrally placed intraperitoneal free air
• Dome sign
• Cupola sign of air under the central diaphragm
• Silver’s sign – visualization of falciform ligament
• Continuous diaphragm sign
• Lucent liver sign – air overlying or outlining liver
• Doges cap sign – triangle of air outlinig morrison’s
pouch
• Inverted V sign - air in umbilical ligaments

16. • Visualization of both the outer and inner walls of a bowel
loop is known as Rigler's sign

17. Causes of pneumoperitoneum
With peritonitis
Perforation of a hollow viscus , peptic ulcer most often
Intestinal obstruction
Ruptured diverticular disease
Penetrating injury – gun shot , knife wounds
Ruptured inflammatory bowel disease(megacolon)
Colonic infections (typhoid)

18. Causes of pneumoperitoneum
Without peritonitis
 Post laparotomy
 Post laparoscopy
 Jejunal diverticulosis
 Steroids
 Tracking from chest (pneumothorax)
 Peritoneal dialysis
 Vaginal insufflation (douching, hysteroscopy)
 Pneumatosis coli

19. Conditions mimicking pneumoperitoneum
Intestine between liver and diaphragm—Chilaiditi's
syndrome
Subphrenic abscess
Curvilinear atelectasis in the lung
Subdiaphragmatic fat
Diaphragmatic irregularity
Cysts in pneumatosis intestinalis
Meteorism
Distended gastric fundus

20. Curvilinear
atelectasis in
the lung

21. Chilaiditi's syndrome

22. Meteorism

23. Fat

24. Peptic Ulcer Perforation
• Aetiology
• Clinical features
• Stages
• Investigation
• Management
• Resuscitation
• Surgery

26. • Fluid levels are common in normal people, and they
usually lie in the colon.
• Three to five fluid levels less than 2.5 cm in length may
be seen, particularly in the right lower quadrant, without
any evidence of intestinal obstruction or paralytic ileus.
• More than two fluid levels in dilated small bowel (calibre
greater than 2.5 cm) are said to be abnormal, and
usually indicate
• Paralytic ileus or
• Intestinal obstruction

27. • The causes of SBO are myriad, but can be largely divided into
• Mural lesions
• tumour,
• stricture due to Crohn's disease,
• irradiation,
• ischaemia
• Luminal
• bezoar,
• gallstone,
• Ascaris lumbricoides bolus,
• intussusception
• Extrinsic
• adhesions,
• hernia,
• volvulus,
• abdominal malignancy

28. Distinction between small- and large-bowel
dilatation
• Dilated small-bowel loops are usually more numerous and arranged centrally in
the abdomen.
• The loops show a small radius of curvature and rarely exceed 5 cm in diameter.
• The presence of solid faeces is the only reliable sign that the loop is large
bowel. The other signs can be misleading.
• The small-bowel folds or valvulae conniventes form thin, complete bands across
the bowel gas shadow, prominent in the jejunum but becoming less marked as
the ileum is reached.
• The valvulae conniventes are much closer together than colonic haustra and
become thinner when stretched.

30. Sigmoid volvulus
The inverted U-shaped loop is usually massively distended
Commonly devoid of haustra, an important diagnostic point.
The ahaustral margin can often be identified overlapping respectively
 the lower border of the liver shadow (the liver overlap sign),
 the haustrated, dilated descending colon (the left flank overlap sign)
 the left side of the pelvis (the pelvic overlap sign).
The top of the sigmoid volvulus usually lies very high in the abdomen
(above the level of T10) with its apex on the left side.

31. Signs
 Grossly distended loop of sigmoid colon
 Coffee bean sign
 Air – fluid ratio > 2:1
 Lack of haustra
 Apex above 10th
thoracic vertebra
 Liver overlap sign
 Left flank overlap sign
 Pelvis overlap sign
 Bird of prey /twisted bird beak appearance

32. Doubt about the
diagnosis on the plain
radiographs
Contrast enema

33. Contrast enema
• Features seen at the point of torsion include a
smooth, curved tapering of the colonic lumen, like a
hooked beak (the bird of prey sign)
• the mucosal folds often show a ‘screw’ pattern at the
point of twist

36. What are the D/D of a radiopaque shadow in this region?
• Kidney stone
• Gallstones
• Pancreatic calculi
• Foreign body
• Fecolith
• Phleboliths
• calcified lymph node
• calcified renal tuberculosis
• calcified adrenal gland
• chip fracture of a transverse process of vertebra or calcification of costal
cartilage

41. What are the important causes of
cannon ball shadows in chest X-ray?
• Metastasis
• Benign lesion
 Fungal infection—Histoplasmosis, coccidioodomycosis,
aspergillosis.
 Parasitic infection—Filarial infection, hydatid disease.
 Sarcoidosis.
 Wegener’s granulomatosis.
 Rheumatoid nodules.

42. Contrast Films
• Barium Swallow
• Barium Meal
• Barium Enema
• IVP

43. Barium Studies
Barium studies can demonstrate GI abnormalities in three ways
1. Mucosal relief views of the collapsed or partially collapsed
lumen obtained with a small volume of barium.
• particularly useful for showing abnormalities involving the
submucosa, such as esophageal varices.
2. Single-contrast views of the filled lumen obtained with a
large volume of low-density barium
• These views enable visualization of contour abnormalities,
strictures, and large polypoid defects.
3. Double-contrast views obtained after the mucosal surface
has been coated with a thin layer of high-density barium
and the lumen has been distended with gas
• These views enable visualization of subtle mucosal lesions, such as
the early changes of inflammatory bowel disease and early
neoplastic lesions

44. • Barium suspensions for single-contrast studies
should be of moderate density (50%-100% w/v)
when not diluted.
• For the double-contrast examination, we use high-
density 250% w/v barium