Important terms used in imaging

X-ray radiographyRadio opacity:A structure which appeare on radiograph is radio

opaque.It is because of more attenuations of x-rays by that structure.

Radio lucency:An area or structure which appear more black copared to adjacent structures is called lucent.It is because of

morre trnsmission of x-rays through that structure.Ultrasound.

A structure which appear on white ultrasound is echogenic and this is because of attenuation of sound waves through that area.

Hypo echoic.Any part or tissue in the body whiich appear more black on ultrasound is hypo ecoic and it is

because of through transmission of sound waves through t5hat part of the bodyCT scan

Hyperdense .CT image is described in term of densities.a white area in the image is hyperdense.Hypodense:a black area appeare is hypodense

Any abnormal area in a structure which has same grey scale appearance is isodenseMRI

MRI image is described in term of intensities.white area in the mri image is hyper tense.A black area in the image is hypointense

An abnormal area of the same color is iso intenseNuclear medicine.These images are described in term of uptake

More uptake in an area is hot less uptake in an area is called cold.Or we called these areas are of high uptake or low uptake

Normal X-Ray chest1:Request form: Check name age gender of tpatient. Check date and time of examination Check if any previous x-ray Check clinical information 2:Technical aspect: Projection PA or AP Position: Upright or supine Orientation. check side marker as there May be congenital anomaly like Dextrocardia. Centering and rotation. Medial end of the

calvicle should be equidistance from the spinous process Penetration. Vertebral bodies and disc spaces

should just be visible through the cardiac shadow.

Portable (AP or Antero-posterior)

FILM

007

PA (Postero-anterior)

FILM

008

Projection

PA AP

009

Low Lung Volumes

010

Over Exposure Proper Exposure

011

99012

013

Clinical and x-ray manisfestations

• Seropositive rh factor is present in blood• Goint pain,fever,weight loss etc• Soft tissue swellings spindle shape of

interphalengeal joints• Osteoporosis• Joint space changes and alignment deformities• Periostitis• Erosions• Secondry osteoarthritis

Exposure factors: If the vertebrae and disc spaces are clearly visible then over exposureIf they can not be seen it means the film is under expose.Over expose film will appear black and under expose film will appear white. Inspiratory efforts:Count the number of ribs above the diaphragm.

*If 10 posterior rib is above the diaphragm---------adequate *If 6 anterior rib is above the diaphragm ----------adequate *If more ribs are visible above the diaphragm-----Hyperexpanded

lungs *If less ribs-----------------------------------------------poor inspiratory efforts Look angles clear or not ,lungs bases clear or not. 3:Review of anatomy: 1.look at the heart.Asses the outline.Apex is

directed to the left or right.Look at the size.It should be 50% of the thorax in adult and 60% in children

016

017

RUL (Right Upper Lung)

018

RML (Right Middle Lung)

019

RLL (Right Lower Lung)

020

Right Sided Fissures

021

LUL (Left Upper Lung)

022

LLL (Left Lower Lung)

023Al-Yami

Left Side Fissure

LUL

LLL

024

Border of the heart:Right border---RT atrium Left border ---Lt ventricle Front ----Rt ventricle Base Lt atrium Apex Lt ventricle Look at the cardiophrenic anglesLook at the mediastinum.It should form one third of the thoracic diameter.Look at the hila.The left hilum is about 2.5cm higher than the right.The hila should be of equal density and size.They should be concave in shape.Look at the lungs field.Examine the lung fields zone by zone and compre the two sides.Look also for the

fissure and lobe.There are three lobs and two fissure on the right. The fissures are horizontal and

oblique.There is only one fissure and two lobe on the left.

Look at the diaphragms.The right is higher than the left .It is because the heart apex is directed to the left.The difference between the two side is 1,5cm if it is more than this it is abnormal.Costerphrenic angles should be clear and sharp.

In a good inspiratory film, the diaphragm should be at the level of 10th posterior rib 6th anterior ribLook at the trachea.It should be cebtral with slight deviation to the right.It divide at the level of T4/T5 in to rt and lt main bronchus.The rt bronchus is shorter and wider than the

left.The left is longer and narrower.Tracheal division is called carina.The angle of carina is 65 to 70 degree.

Look at the bones.The density of bones should be similar on both sidesLook at the soft tissue of the chest wall Look at the hidden areas. They are clearly in the LA view. The hidden areas are Retrocardiac,retrosternal,costopherinic and cardiopherenic angles apices,lung bases and hila and domes of

diphragm

Rhumatoid arthritis

• Autoimmune inflamatory disease• Occre in adults• Multisystemic disorder• Seropositive arthritis• Mainly affect the small joints of the hands and

feets• Cervical spine and rarly large joints are also

affected,specially atlantoaxial and shoulder joint

Invistigations

• X-ray• Ultrasound• CT• Radionuclide studies• MRI

Psoriasiatic arthritis

• Seronegative arthritis• Affect the small jpints of hands and feet• Nail changes and skin• Affect and distal interphalangeal goints• Affect the spine with syndesmophyte

formation• Sacroillitis

Reiters disease

• Syndrome of arthritis,urethritis and conjunctivitis

• Affect the feet more than the hands• Painfull erosion of calcaneus with spur

formation• Sacroillitis

Ankylosing spondylitis

• Seronegative arthritis• HLA –B27 is positive• Affect young adults• Mainly affect the spine with chacteristic changes• Squaring of vertebral bodies and bamboo spine• Sacroillitis is bilateral and symetrical.sacroillic

joints are assesed with prone view of sacroilliac joints

Gout

• A metabolic disease with abnormality of uric acid

• Affect the great toe of feet• Bone erosions• Osteoporosis • Tophi formation

Osteoarthritis

• Degenerative disease• Affect mainly the weight bearing joints• Primary when no cause is known• Secondry when the goint is abnormal• Mainly affect old people• Main complain of patient is pain and stiffness• More common in over wight people

X-ray appearences

• Joint space narrowing• Increase bone density• Osteophyte formation• Loose body• Cyst formation• Vacuum phenomenon in the intervertebral

spaces

Invistigations

• X-ray• CT scan

Spondylolisthesis

• When there is slip of one vertebra over another

• Usually occure due to stress fracture in the parse

• Four grades• 25%• 50%• 75% AND TOTAL

OSTEOPOROSIS

• Due to decrease bone mass• Decrease bone mass result in increase incidence of

fracture• Senile osteoporosis occue in old people.there is loss

of cortical and trabecular bone.Fracture occure more commonly in femoral neck and humerous

• Postmenopausal osteoporosis.occure in womenabove 50 years of age.vertebral fractures are more common

Rickets

• Vitamin D defficency disease• Occure in childern• There is lack of mimeralisation of bones• Lack of vitamin D• Lack of calcium• The above defficiency may be either

nutritional or disease process

X-ray appearences

• Loss of normal zone of proviosnal calcification• Fraying of growth plate• Splaying cupping of metaphysis• Osteoporosis• Pigeon chest• Rickety rosy

Osteomalacia

• Vitamin defficency disease occure in addults• More common in females• Bone become soft so bowing occure• Looser zones bilateral and symetrical• Compression of vertebrae• Cordfish vertebra

Tumors of bones

• Classification• Two groups 1:primary 2: Secondary

tumors. Primary are divided in to a) benign and malignant

• Primary bone tumors• A: Benign 1.bony island 2.osteoma.3.osteoid

osteoma 4 osteoblastoma• B: Malignent .Osteosarcoma

Cartilage tumors

• A. Benign 1.osteochondroma 2.chondroblastoma etc

• Malignent: chondrosarcoma

Tumors arising from other bone tissues and tumor like condition.

• 1:Gaint cell tumors• 2 : Aneurysmal bone cyst3:hemangioma• 4:Ewing sarcoma 5:

Osteoid osteoma

• Benign bonr forming tumor.small in size with a lucent central nidus .Give pain at night and only releived by asprine

• Osteoblastoma. Same as osteoid osteoma but larger in size and pain is not releived by asprine .both these tumors occure in young adult

Malignent tumors of bone and cartilage

• Osteosarcoma.Occure commonly in childern causing bone destruction,soft tissue and mrtastasis

• Chondrosarcoma: Malignent cartilaage tumor.more common in old people cause destruction of cartilage,soft tissue mass with calcification and metastasis in advance cases.

Ewing sarcoma

• Special bone tumor.More common in childern causing bone erosion and clinical and radiological appearences are like bone infection

Neuropathic or charcot goints

• Causes are DM,syphilis and other neuropathies.There is denervation of the involved goints and loss of pain sensations

• X-ray appearences. Bone destruction-increased bone density-debries in joints-disorganization of joints.

Osteomalacia

Ricket

Charcot,s joint

Ricket in a child

Respiratory systemPulmonary tuberculosis.

• It is an infectious diseas caused by mycobecterium tuberculosis.

• It mainly involve the lungs,although it can affect any organ in the body.

• Two groups 1:Typical 2:Atypical• Typical are Mycobecterium tuberculosis and M,bovine• Atypical are-M,avium intracellulare.M,kansasi• And M,xenapi etc• Disease is common in poor class,alcoholics and aids

patients

Primary tuberculosis

• Usually heals with out complications• Sequence of events includes Consolidation Caseation Lymphadenopathy pleural effusionSpread of primary occure in childern and

immunosupressed.

ComplicationsMilliary TB,pleural effusion

pneumothoraxtuberculoma

bronchopleural fistula

Atypical TB

• Caused by atypical organisms as mentioned above

• The presentation may not be distinguished from fron typical

• Treated by second line of drugs

Post primary or secondry tubercolosis.

• Common in adults,usually occure as re,infection.

• Common in apical segments of upper lobes.• Features includes. patchy consolidation cavitation fibrosis calcification

X ray chest shows T.B in both lungs field

Milliary TB

PA view chest• Routine view of chest• PA is usually done in errect

position• Cassete is in front and X-ray

source is behind• PA view minimise cardiac

magnification• PA is sharper,lungs fields

appear clear• Lungs bases CP and

cardiophrenis angles are clear

AP view chest• Usuallu done in emergency• It is done in supine position• Cassete is behind and x-ray

source is in front• Heart and mediastinum

appear enlarge• The closer structure to the

image source appeare enlarge.• Lungs fields are not as clear as

PA view

PA• Scapullae are removed from

lungs fields.• Ribs appear more horizontal• PA is easy to read• It is easy to lower the

diaphragm in PA

AP• The scapullae is projecting

over the lungs fields.• The ribs appear more

vertical• AP is difficult to read• There can be 15% difference

between width of mediastinum in AP and PA

Some definitions

• Radiolucency.The area which appear black on the X-ray.It is because of through transmission of x-rays through that part.

• Radiopacity.Such area appeare white on the x-ray.It is because of more attenuation or absorption of x-rays.eg pneumonia,bony structures

• Consolidation.The replacement of air in the lungs by fluid without any change in lungs volume is consolidation.eg pneumonia etc

Cont definitions• Dextrocardia.Abnormal position of heart in the RT hemithorax with the apex

pointing to the right.It occure with transposition of viscera or some time with out transposition.

• Pneumomediastinum.Air in the mediastinum.the causes are infection,trauma and tumors

• Silhouette sign.When there is loss of interface between lungs and adjacent structures eg heart and diaphragh.It help in the localization of lungs pathology.Heart and lungs are normally seen because there is adjacent aereated lungs.When air in the adjacent lungs is replaced by fluid,these borders are no longer seen.

• Hilum overlay sign.It differentiate between enlarge heart and mediastinal mass.

• Cervicothoracic sign.A welldefined mass seen above the clavicle in the lungs is always posterior wheae as anterior mass is in soft tissue and is not welldefined.this is cervicothoracic sign.

Pneumonia.

• It is an inflamatory reactions in the lungs.• Primary pneumonia.inflamation occure in normal

lungs.• Secondry pneumonia.Inflamation occur when there

is occlusion of bronchus eg tumors or foreign body.• Lobar pneumonia.When pneumonia is confined to

one lobe cause by streotococcus pneumoniae.• Bronchopneumonia.When there are bilateral

multifocal areas of consolidations

Types of pneumonias

• Viral-common in childern• Bacterial –eg streptococcus etc• Mycoplasma-Atypical pneumonia• Legionella pneumonia.rapidly progressive

pneumonia• AIDS.Pneumocystis carani pneumonia.• Radiation pneumonia.consolidation in the

field of radiation

Radiological features of pneumonia

• Because of inflamation air in the lungs is replaced by fluid which may be confined to one lobe(lobar pneumonia) or multifocal in one or both lungs field( bronchopneumonia)

• There may be associated pleuraleffusion.

Pneumothorax.

• Collection of air in the pleural cavity is called pneumothorax.

Causes.Spontaneus Trauma Iatrogenic Pre-existing lung disease.

Radiological features of pneumo--

• Best demonstrated by underpenetrated and expiratory film

• The area appeare lucent .• There is underlying lung collapse• Absent lung marking between lung edge and chest wall.• Lung edge .a thin white line of lung margin is seen, the

visceral pleura.• Mediastinal shift is seen when there is tension

pneumorax.Tension pneumothorax is an emergency and treated by lung entubation.

Treatment of pneumothorax

• Small pneumothorax usually require no treatment.large pneumothorax is generally treated by putting a tube in the pleural cavity with an under water seal, follow up film are required .

Pleural effusion

• Collection of fluid in the pleural cavity.It is usually serous fluid.

• Haemothorax.If the fluid is blood-common in trauma

• Chylothorax.If the fluid in the pleural cavity is lymphatic.common in malignent tumors

• Empyema.when the fluid in pleural cavity is pus-cause is infection

• Hydropneumothorax.When both air and fluid collect in the pleural cavity

Type of pleural effusions

• Free pleural effusion.It is free to move and gravitate to the most dependent part of the lungs

• Encysted pleural effusion.• Lamillar pleural effusion.Along the chest wall• Subpulmonary .Between the diaphragm and

inferior surface of the lungs

Radiological appearance of PL effusion

• Fluid appear radiopaque• First there is blunting of costopherinic angles• There is loss of diaphragmatic and cardiac outline• When the fluid increase in volume it assume a crescent

shape• Further increase of fluid opaque the whole hemithorax

if effusion is unilateral• There may be shift of mediastinum or underlying lunf

collapse• Treatment is by intubatation and aspiration

Cavitating lesions in the lungs

• Causes.Infection,tumors,trauma and congenitial lesions.• Abscess formation within cosolidated area of lung occur

due to becterial infections.some organism like staphylococci produce cavity.

• Cavity also occure due to tumors.• Malignent tumors produce thick wall cavity• Tha inside of the wall may be nodular in malignent

lesion but smooth and thin in benign lesion.The cavity may contain fluid,but if it communicate with bronchus,air fluid level is produced in the cavity.

Bronchiactasis.

• Irreversable dilation of the bronchi is called bronchiactasis.There my be impairment of drainage which may lead to secondry infection

• Presentation.Cough with purulent sputum.• Causes.Childhood infection Fungal infections Bronchial obstruction Cogenital.Kartagners syndrome.

Bronchiactasis

Emphysema

• Emphysema is chronic lung disease in which there are over inflation of the air spaces specially the alveoli with destruction of its wall

• The patient present with shortness of breath• It is common in old people• It usually occur with other lung diseases

specially chronic bronchitis.• It can be congenital and occur in infancy

Emphysema

Radiological appearences

• The chest x-ray may be entirly normal• Cylindrical.Dialated bronchi may be visible as

parallel lines.• Cystic.dilated bronchi may be visible as cysts.• Pneumotic consolidation• Fibrotic changes.

• Complications are empyema,cerebral abcess.

10 radiological views for chest

• PA view in full inspiration• PA view in expiration for pneumothorax• LA view chest• AP supine• AP errect eg when patient has khyphosis• Apical view• Apical lordotic view• Oblique views• Lateral decubitius view• Lordotic view To demonstrate middle lobe collapse

Lungs tumors

• Primary and secondry• Primary is divided in to benign and malignent• Benign are adenoma,hamartoma and

carcinoid• Mlignent.bronchogenic carcinoma,sarcoma

lymphoma and metastasis

Brongenic carcinoma

• Commonest malignent tumor of the lungs occur commonly after the age of 50 years

• More common in male and smookers• Clinically present with cough,sputum,shortness

of breath,chest pain and hemoptysis.• Radiological sign are.

• Peripheral mass

Bronchogenic carcinoma

• Mediastinal lymph node enlargment• Cavitation and consolidation• Carcinoma in the apical region is called

pancost tumor.

Abdomen.

• Acute abdomen is an emergency.• Causes of acute abdomen Acute intestinal obstruction acute pancreatitis acute appendecitis acute cholecystitis renal colic acute slphangitis ovarian torsion trauma etc

Radiographic technique acute andomen

• 1:x-ray chest PA view in errect position• This view is important for the detection of

pneumoperitoneum especially on the RT side between the liver and diaphragm.

• Abdomen errect.This film show fluid level in the abdomen.• Supine abdomen.This the pattern of distribution of gas in

intestine• LA abdominal view.This help in detection calcification in

aorta and also differentiate calculus from calcified lymph nodes.

Radiographic tachniques

• La decubitus film.RT and LT lateral decubitus film help in the detection of pneumoperitonium.The technique is put the patient in the left lateral position with rt side up for 10 minutes and take a horizontalray film.This technique detect small pneumoperitoneum.It can also detect small amount of ascites when fluid collect in the dependent part of abdomen.

Pneumoperitoneum

• Collection of air in the peritoneal cavity• Causes.1.perforation of gastric ulcer 2.perforation of other viscus 3.post operative 4.post operative 5.post embolization 6.peritonitis 7.perforated appendecitis etc

Errect chest shows pneumoperitoneum

Radiographic appearances of small and large intestine

Small intestine• Vulvulae connivente are

present• Many loops are present.• Loops are distributed in the

centre• Haustra are absent• Diameter is 3-5cm• Radius of curvature is small• Solid faeces absent• Length is about 6 meter

Large intestine• Volvulae conniventes are

absent• Few loops are presents• Loops are distributed in

periphery• Haustra are present• Diameter is 5cm+• Radius of curvature is large• Solid faeces present• Length is 1.5 meter

Small intestine Large intestine

Intestinal obstruction

• Dynamic obstruction.due to tumor,stricture or extrensic compression by a mass

• Adynamic obstruction.It is also called paralytic ilius.causes are peritonitis and postoperative

• Clinical presentation.Pain,distension,tenderness,vomitting and absolute constipitation

Intussusception

• When one segment of the intestine prolapse in to the adjacent of the intestine.It is common in childern at the age of 2 years but also occur in adult.the causes are tomor ,enlarge lymph nodes etc.

• The clinical features are colicky abdominal pain,vomitting and bloody diarrhea.

• Plain film show a mass in the proximal bowel and contrast study show a coiled spring appearance.

The management is either reduction by contrast enema or surgery