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Lecture 2
Chest X-RayTechnical Consideration
• Entire chest should be included• Thoracic vertebrae should be barely seenThoracic vertebrae should be barely seen
through heart on PA film• Optimal inspiration – diaphragm at level of
10th rib posterior• Medial clavicles (anterior midline)
equidistant from spinous processes (posterior midline)
• Ribs slightly offset on lateral
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Chest Normal
Normal Chest Anatomy
• Right heart border– Upper portion - SVC and
ascending aortaascending aorta– Lower portion – right atrium
• Left heart border– Upper portion – aortic arch– Mid portion – main
pulmonary artery– Lower middle portion – left p
atrium– Lower portion – left
ventricle
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Normal Chest Lateral
• Anterior heart border– Upper portion –pp p
aortic arch– Mid portion –
pulmonary artery– Lower portion – right
ventricle• Posterior heart borderPosterior heart border
– Upper portion – left atrium
– Lower portion – left ventricle and IVC
Chest Normal
RULLUL
RML/
RUL
LUL/
RUL/LUL
RLL/LLL
RML/LUL
RLL LLLL UL
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Pulmonary Lobes
RML/RL
RUL LUL
LUL/L
RUL/LUL
RLL/LLL
RML/LUL
Frontal Lateral
L LL L
Normal Pulmonary Vascularity• Lung markings
branch and taper symmetricallysymmetrically
• Upper markings sparser and thinner than mid and lower on upright filmupright film, difference less prominent on recumbent studies
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Normal Pulmonary Vascularity
• Easily see vessels in inner thirdinner third
• Vessels identified but less prominent middle third
• Difficult to see discrete vessels outerdiscrete vessels outer third
Cardiac Radiography
• Frontal view– Left ventricular – Left atrial appendage– Pulmonary artery– Aorta– Superior vena cavaSuperior vena cava
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Cardiac Radiography
• Lateral view– Right ventricular size– Posterior border left atrium– Posterior border left ventricle– PA dimension of thorax
• Oblique views• Oblique views– Optimize evaluation of cardiac margins
Cardiac Radiography
RA
SVC
PA
RV
IVC
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Cardiac Radiography
AA
LA
LV
Cardiac Radiography
RA
SVC
AA
DA
RV
RPALPA
MPA
IVC
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Cardiac Radiography
LV
LA
MV
AV
LV
Cardiac Radiography
• Cardiac size– 50% or less of the trans thoracic diameter– UP to 60% in children– Cardiac thoracic ratio– Caution!! Poor inspiration false increase in
cardiac size– Evaluate both frontal and lateral views– Pericardial fluid also can cause apparent
cardiac enlargement
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Reading the Chest X-raya Systematic Approach
Diaphragm• Diaphragm• Pleura• Costophrenic angles• Lungs
H t d t l• Heart and great vessels• Trachea and mediastinum• Bones and soft tissues
Chest Normal
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What Is the
Finding?
What Is thethe
Finding?
Absent Left
Breast
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Where Are theAre the Shotgun Pellets?
3-D Imaging• Lateral view
reveals pellets in thepellets in the anterior aspect of the chest wall
• Need perpendicular p pview to ascertain exact location
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Where is the Straight Pin?
Where Is the Straight Pin?
• Straight pin in the b hbronchus
• Lateral view is needed for 3-dimensional orientation
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Acute Abdominal Series
• Supine abdomen (KUB, “flat plate”)• Upright abdomen –
– detects air-fluid levels and free intraperitoneal air, horizontal beam (parallel to the floor);
– Patient needs to maintain position for at least 10 minutes prior to obtaining x-rays10 minutes prior to obtaining x-rays
Acute Abdominal Series
• Chest x-ray – detects free intraperitoneal air and chest pathology
• Left lateral decubitus abdomen – substitutes for upright view in debilitated
patients, ti t d t i t i iti f t l t 10– patient needs to maintain position for at least 10
minutes
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Abdominal Imaging PositioningRadiographic Appearance
• SupineAir in body of stomach
• UprightAir in fundus– Air in body of stomach
– Air in transverse colon
• Prone– Air in fundus of
stomach
– Air in fundus
• Decubitus– Right side up air in
right colon andstomach– Air in rectum– Air in ascending and
descending colon
right colon and duodenum
– Left side up air in left colon and stomach
Reading the Abdominal X-ray(ABCD Approach)
A. -- Air (air pattern, free air)B. -- BoneC. -- CalcificationsD. -- Density (soft tissue)D. Density (soft tissue)
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Normal Mucosal Folds
A. Valvulae conniventes of small intestine
B. Haustra of colon
C G t iC. Gastric rugae of stomach
A B C
Normal Acute Abdomen
• Normal abdomen
• Upright abdomen• Air-fluid level
stomach fundus• Stool in colon
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Normal Chest, Acute Abdomen
Study
• No free air• No chest
disease
Normal Acute Abdomen
Series• Supine film• Normal gas
distribution• No masses• Normal organs
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Uroradiologic Studies• X-Ray:
– Plain film, KUB (Kidneys Ureter Bladder) and tomographyg p y
– Intravenous Urography (IVU)– Voiding CystoUrethroGraphy (VCUG)– Angiography and Digital Subtraction Angiography
(DSA)• Ultrasound (US)• Computed Tomography (CT) and Magnetic p g p y ( ) g
Resonance Imaging (MRI)• Radionuclide renal scan• Positron Emission Tomography (PET)
Normal Urinary Tract Anatomy
• Renal parenchyma:– Cortex, medulla
• Urinary collecting system:– Calyces, infundibula, pelvis, ureters
• Urinary bladderU th• Urethra
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Normal KUB Film
• Kidneys Ureter Bladder (KUB)Bladder (KUB)
• Supine• Left kidney visualized• Right kidney partially
obscured• Evaluate kidney size,Evaluate kidney size,
shape, position and presence/absence of calcifications
Normal KUB Film
• Evaluate kidney size9 13 cm– 9-13 cm
• Shape-– Reniform– Bean shaped
• PositionP ll l t th– Parallel to the psoas muscles
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Anatomic Correlation
• Normal Anatomy
PsoasMargin
PsoasMargin
IVU Tomogram• Immediately after contrast injection• Contrast in proximal tubules
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Intravenous Urogram (IVU)
• Indications– Hematuria– Trauma– Abdominal Pain (referred to urinary tract)– Palpable abdominal mass– Mass or calcification on KUB
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Mass or calcification on KUB
Iodine Contrast Physiology
• Intravenous contrast excreted by Glomerular FiltrationFiltration
• Concentration of filtrate = concentration in the plasma
• Proximal tubule water resorption increases contrast concentration 5 - 10 foldDi t l T b l /C ll ti t t ti
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• Distal Tubule/Collecting system water resorption increases contrast concentration to a total of 30 - 50 fold greater than plasma concentrations
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IVU
• Insignificant contrast secretion– <2% excretion by liver and small bowel– Primary route of clearance in renal failure
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IVU
• Risks– An incidence of allergic reaction
• Not dose related• May be related to Iodine or carrier molecule• Use of non-ionic agents
– Renal failure exacerbation
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• Low function to start• Multiple Myeloma
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Nephrotoxic Effects of Contrast
• Ionic Contrast– Hyperosmolar to plasma– Significant risk of inducing renal failure
• Especially if “at risk”– Relatively inexpensive
• Non-Ionic Contrast
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Non Ionic Contrast– Recent innovation ~1970– Reduces risk of inducing renal failure– Increase cost – initially 25x ionic contrast
Nephrotoxic Effects of Contrast
• Non-Ionic Contrast– Recent developments
• Even lower osmolality• May reduce risks even more
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IVU
• Nephrogram-– Contrast concentration in the renal
parenchyma– Short period immediately following injection– Rapidly disappears as contrast moves into the
calyces and renal pelvis
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Renal Size and Contours
• Size– Symmetric– 9-12 cm in adults– <1cm difference right to left
• ContoursSmooth or slightly undulating
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– Smooth or slightly undulating– Occasional lobulation especially on left
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Normal IVU
Normal Examination
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IVU Tomogram
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CT Indications
• Indications• Suspicion of ureteral calculi (Procedure of
choice)– Evaluation of all retroperitoneal structures– Renal mass by other modalities– Hematuria with suspicion for renal neoplasm
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– Hematuria with suspicion for renal neoplasm– Staging of neoplasm
• Prostate• Ovary
CT Normal Anatomy
Superior Mesenteric Vein
Superior Mesenteric ArteryAortaVena Cava
DuodenumRenal Pelvis
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Crus of Diaphragm
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CT Urogram
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CT Urogram
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CT Angiography
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US Principles
• High frequency sound– Relatively uniform speed of transmission inRelatively uniform speed of transmission in
tissues– Passes through fluid without interaction– Reflected by bone and air
• Acoustic windows
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– Liver for right kidney– Left more difficult no good window– Bladder for Pelvis
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Normal Renal US
Normal Right Kidney
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Normal Renal US
Normal Right Kidney
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Normal Bladder
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MRI NormalNormal kidneys
Liver
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MRI Normal 2
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MR Angiography
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Normal Flow
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Radionuclide Renal Scan• Normal
perfusion • IV injection j
followed by imaging every 3 seconds
• See uptake in aorta, arteries, kidneyskidneys
• Allows evaluation of blood flow