X rays

Radiographs
Surgical unit 1
BBH
2Dr Sadia Jaskani
PGT-SU-1
BBH

Abdominal X-Ray Projections:
•Supine 99%
•Erect
•Lateral decubitus.
Knowledge of the anatomy of the abdomen
allows localization of the abnormalities
observed on the AXR.
3
Dr Sadia Jaskani
PGT-SU-1
BBH

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Supine
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Erect
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Lateral decubitus
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Dr Sadia Jaskani
PGT-SU-1
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Assess the Film in Detail:
A simple guide to interpretation is shown below. Working
through these headings one covers, ‘dark bits’, ‘white bits’,
‘grey bits’ and ‘bright white bits’ in turn.
‘BLACK BITS’
•Intra-luminal gas can be normal.
•Extra-luminal gas is abnormal.
•However, intra-luminal gas can be abnormal if
it is in the wrong place or if too much is seen.
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‘BLACK BITS’ (Continued) - Intra-luminal gas:
•The maximum 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 caecum is not said to be dilated
unless wider than 80mm.
•Large and small bowel may be distinguished by looking at
bowel wall markings
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Dr Sadia Jaskani
PGT-SU-1
BBH

Characteristic Small bowel
Large
bowel
Haustra Absent Present
Valvulae conniventes
Present in
jejunum
Absent
Number of loops Many Few
Distribution of loops Central Peripheral
Radius of curvature of
loop
Small Large
Diameter of loop 30–50 mm 50 mm+
Solid faeces Absent
May be
present
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Dr Sadia Jaskani
PGT-SU-1
BBH

The haustra of the large bowel extend only a third of
the way across the bowel from each side, whereas the
valvulae conniventes of the small bowel tranverse the
complete distance.
Intra-luminal gas (continued):
It is usual to see small volumes of gas throughout the
GI tract and the absence in one region may in itself
represent pathology.
For example, if gas is seen to the level of the splenic
flexure and nothing is seen beyond this, a site of the
obstruction at this site – a ‘cut off’ point is noted.
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Dr Sadia Jaskani
PGT-SU-1

Causes of Extra-luminal gas:
•Post Abdominal Surgery/ERCP
•Perforation of viscus (eg. bowel, stomach)
•Gallstone ileus
•Cholangitis (infection with gas forming organisms)
•Abscess
An erect CXR (not AXR) is the best
projection to diagnose a
pneumoperitoneum (gas in the peritoneal
cavity).
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Dr Sadia Jaskani
PGT-SU-1
BBH

‘WHITE BITS’ = Calcification
Calcified structures (‘WHITE BITS’) are often seen on
AXR.
The main question is – does its presence
have any important implications
Bones are normal ‘white’ structures. On the AXR they
comprise mainly those of the thoraco-lumbar spine and
pelvis. Findings are largely incidental as direct bone
pathology would be investigated with specific views.
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Dr Sadia Jaskani
PGT-SU-1
BBH

‘GREY BITS’ = Soft Tissues
Soft tissues represent most of the contents of the
abdomen and feature heavily in the AXR.
However, 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.
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Dr Sadia Jaskani
PGT-SU-1
BBH

‘BRIGHT WHITE BITS’ = Foreign Bodies
•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.
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Dr Sadia Jaskani
PGT-SU-1
BBH

mnemonic for what to do next
• Big Spanish Cuddly Giant Again
• (i.e. Bone, Soft tissue/Solid Organs,
Calcification, Gas pattern & Artefacts)
but I feel sure you could come up
with your own
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Dr Sadia Jaskani
PGT-SU-1
BBH

Feeding tube
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PGT-SU-1
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CVP
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Dr Sadia Jaskani
PGT-SU-1
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X-rays of GIT
A brief reveiw
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PGT-SU-1
BBH

• A plain x ray of the abdomen in erect
position shows multiple air fluid levels
that indicate intestinal obstruction
• Intestinal obstruction may be
• Dynamic, where peristalsis is working
against a mechanical obstruction
• Adynamic, when there is no mechanical
element.
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Dr Sadia Jaskani
PGT-SU-1
BBH

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PGT-SU-1
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Dr Sadia Jaskani
PGT-SU-1
BBH

• These plain x rays of
the abdomen in the
supine position show
dilated jejunal loops
that are
charcterized by the
valvulae
convenintes(Looks
like an accordion)
and dilated illeal loop
(stuctureless type)
described by
wagenstein 22
Dr Sadia Jaskani
PGT-SU-1
BBH

• The obstructed
small bowel is
characterized by
straight segments
that are generally
central and lie
transversely. No
gas is seen in the
colon. The supine
film is superior
than the erect film
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Dr Sadia Jaskani
PGT-SU-1
BBH

• Valvulae
conniventies
pass across
the width of
bowel and are
regularly
spaced
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Dr Sadia Jaskani
PGT-SU-1
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• Rigglers sign:
luminal and
external
border of the
bowel are
visible
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PGT-SU-1
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Dr Sadia Jaskani
PGT-SU-1
BBH

sigmoid volvulus
• Plain x ray
abdomen
• twisting or axial
rotation of
sigmoid colon
about its
mesentry
• Omega sign/
coffee bean sign
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Dr Sadia Jaskani
PGT-SU-1
BBH

This is the coffee
bean sign
It is seen in sigmoid
volvulus
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Ceacal volvulus
• A barium enema
may be used to
confirm the
diagnosis, with an
absence of
barium in the
ceacum and a bird
beak deformity
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Dr Sadia Jaskani
PGT-SU-1
BBH

duodenal atresia
• Double bubble
appearance
• It occurs due to
gross distension
of stomach and
upper duodenum
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Dr Sadia Jaskani
PGT-SU-1
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free gas under the diaphragm
• X ray erect chest
• Hollow viseral
perforation
• Absence of gas
under diaphragm
does not exclude
the diagnosis of
viseral perforation
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Dr Sadia Jaskani
PGT-SU-1
BBH

• X-ray erect
chest---gas
under
diaphragm
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Dr Sadia Jaskani
PGT-SU-1
BBH

Inguinal
hernia
• Distended
gut loops
at the
level of
deep
inguinal
ring
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Dr Sadia Jaskani
PGT-SU-1
BBH

X ray showing foreign body in the
rectum
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Dr Sadia Jaskani
PGT-SU-1
BBH

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Dr Sadia Jaskani
PGT-SU-1
BBH
X ray showing foreign body in the
rectum

•This is the ‘bird beak’ sign
•It is seen in achalasia
•It apparently looks like a bird’s beak (see
below)
36

• Barium swallow x ray showing the
dilated esophagus down to lower
end, smooth tapering of lower
esophagus(dysphagia)
• Bird beak deformity
• Rat tail appearance
• Pencil tip sign
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Dr Sadia Jaskani
PGT-SU-1
BBH

This is an ‘apple-core’
lesion
These are almost always
cancer (in this case it is a
caecal carcinoma)
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Dr Sadia Jaskani
PGT-SU-1
BBH

Pyloric
obstruction
• Huge sized
stomach
• No dye seen
beyond pyloric
sphincter
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Dr Sadia Jaskani
PGT-SU-1
BBH

Leadpipe colon
• Barium enema showing
loss of haustrations
and narrowing of
sigmoid and
descending parts of
the colon
• Characteristic of
ulcerative colitis
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Dr Sadia Jaskani
PGT-SU-1
BBH

Lead pipe colon!!
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Dr Sadia Jaskani
PGT-SU-1
BBH

String of kantor
• Seen in
crohn's
disease
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Endoscopic
cholangiopancreatography
Dr Sadia Jaskani
PGT-SU-1
BBH

Clinical anatomy
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Dr Sadia Jaskani
PGT-SU-1
BBH

• ERCP
• Showing
normal CBD
and
pancreatic
duct.
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Dr Sadia Jaskani
PGT-SU-1
BBH

Filling
defects in
CBD
• ERCP
• Showing
dilated CBD
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Dr Sadia Jaskani
PGT-SU-1
BBH

• ERCP Showing
stone in lower
part of CBD
and pancreatic
duct.
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Dr Sadia Jaskani
PGT-SU-1
BBH

Gall stones
• Cholesterol and pigment
stones are radiopaque and
visible on radiographs in
only 10-30% of instances,
depending on their extent
of calcification
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Dr Sadia Jaskani
PGT-SU-1
BBH

Porcelain Gall Bladder
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Dr Sadia Jaskani
PGT-SU-1
BBH

Pancreatic calcifications
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Dr Sadia Jaskani
PGT-SU-1
BBH

These are ‘stag-horn’
calculi
Do not confuse this with
an IVU; no contrast has
been used here
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X ray KUB
• showing radio
opaque
shadows
consistent with
renal stones
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Dr Sadia Jaskani
PGT-SU-1
BBH

Bladder calcifications.
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Dr Sadia Jaskani
PGT-SU-1
BBH

X ray showing urinary bladder stones
• Pure uric acid
and ammonium
urate stones
are
radiolucent
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Dr Sadia Jaskani
PGT-SU-1
BBH

Urinary bladder stones
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Dr Sadia Jaskani
PGT-SU-1
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Intravenous urography
• Urinary
bladded Filling
defect
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Mammographs
Dr Sadia Jaskani
PGT-SU-1
BBH

BI-RADS standardized categories
• Category 0, or "need additional imaging evaluation," is used if additional
imaging is needed/screening situation
• Category 1, or "negative," is used if there are no findings to comment on
• Category 2, or "benign finding(s)," to describe a benign finding while still
concluding that there is no mammographic evidence of malignancy.
• Category 3, when a noted finding has a very high probability of being benign
• Category 4, or "suspicious abnormality–biopsy should be considered," is used
when a finding has a definite probability of being malignant
• Category 5, or "highly suggestive of malignancy–appropriate action should
be taken," is used when a finding has a high probability of being cancerous
• Category 6, or "known biopsy-proven malignancy-appropriate action should
be taken," is "reserved for lesions identified on imaging study with biopsy
proof of malignancy prior to definitive therapy"
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Dr Sadia Jaskani
PGT-SU-1
BBH

Normal mammogram
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Dr Sadia Jaskani
PGT-SU-1
BBH

Mammographic images showing well
circumscribed mass, well defined
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Dr Sadia Jaskani
PGT-SU-1
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Mamogram showing macrocalcifications
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PGT-SU-1
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Mammograph showing diffuse calcifications
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PGT-SU-1
BBH

Pneumothorax
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PGT-SU-1
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Peumothorax
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PGT-SU-1
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Hemothorax/hydrothorax/pyothorax
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PGT-SU-1
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Hemothorax
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PGT-SU-1
BBH

Hemopneumothorax
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PGT-SU-1
BBH

Hemopneumothorax
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PGT-SU-1
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Tension pneumothorax
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Flial chest
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PGT-SU-1
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Chest tube
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PGT-SU-1
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Chest tube
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Dr Sadia Jaskani
PGT-SU-1
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Mesothelioma
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Dr Sadia Jaskani
PGT-SU-1
BBH

CA lung
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PGT-SU-1
BBH

ARDS
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Dr Sadia Jaskani
PGT-SU-1
BBH

Cardiac temponade
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Dr Sadia Jaskani
PGT-SU-1
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Aspergilloma
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Dr Sadia Jaskani
PGT-SU-1
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Ct scan
Dr Sadia Jaskani
PGT-SU-1
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Dr Sadia Jaskani
PGT-SU-1
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Normal anatomy
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PGT-SU-1
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Trauma situations
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CT scan brain
Dr Sadia Jaskani
PGT-SU-1
BBH

Extradural hematoma
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PGT-SU-1
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Subdural hematoma
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PGT-SU-1
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Subarachanoid hamorrhage
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PGT-SU-1
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Intraparenchymal bleed
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PGT-SU-1
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Base of skull fracture
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PGT-SU-1
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Dr Sadia Jaskani
PGT-SU-1
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Depressed skull fracture
Dr Sadia Jaskani
PGT-SU-1
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93
All the best
Dr Sadia Jaskani
PGT-SU-1
BBH

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