Back to Basics Radiology 2010 Rebecca Peterson Department of Radiology University of Ottawa

Routine Technique: PA and Lateral

Normal Chest – PA and Lateral

PA Chest Trachea SVC Aortic arch Azygous Lt Pulm Artery Rt Hilum Lt Mainstem bronchus Lt Ventricle Rt Atrium Rt Diaphragm Lt Diaphragm

Lateral Chest Aortic Arch Trachea Lt Pulm Artery Rt Pulm Artery Lt upper lobe bronchus Rt Ventricle Lt atrium Rt Diaphragm Lt Ventricle Lt Diaphragm

Consolidation Without volume loss With volume loss Pneumonia, Pulmonary edema, Hemorrhage With volume loss “Atelectasis” or “Collapse”

Consolidation Without Volume Loss

Consolidation With Volume Loss

Consolidation Means “solid lung” Characteristics: Increased density Acinar shadow Silhouette sign Air bronchogram

Consolidation and Air Bronchogram CT Scan

Consolidation, Air Bronchogram and Silouhette Sign PNEUMONIA

Consolidation Without Volume Loss Airspace Disease

LLL Pneumonia Consolidation Sharp interface Loss of diaphragm NORMAL

LLL Pneumonia consolidation Sharp interface Loss of lt diaphragm NORMAL LLL PNEUMONIA

Normal RML Consolidation Loss of heart border

Normal RML Consolidation Consolidation

RLL Pneumonia PA View Lateral

Lingular Pneumonia Lateral PA View

Right Lower Lobe Pneumonia

LLL Pneumonia

Causes of Airspace Disease Pneumonia Hemorrhage Pulmonary Edema Neoplasm Other

Consolidation With Volume Loss Atelectasis or Collapse

Passive Atelectasis

Endobronchial Lesion

Signs of Volume Loss Direct Signs: Movement of a fissure Indirect Signs: Elevated diaphragm Tracheal shift Mediastinal shift Elevated or lowered mainstem bronchus Movement of hilum Fewer vessels in aerated lung

Right upper lobe collapse Tracheal shift Hilum displaced Elevation of diaphragm Movement of the Fissures, a DIRECT sign of volume loss

RLL Collapse Tracheal shift Fissure displaced Collapsed lung Hilum pulled down

Normal Atelectasis LLL No diaphragm Diaphragm reappears Portable Chest X-ray

LLL Atelectasis

Complete collapse Tracheal shift Bronchus amputated Diaphragm

Pleural Effusion

Pneumothorax and Pleural Effusions Pleural Diseases Pneumothorax and Pleural Effusions

Pneumothorax

Tension Pneumothorax INSPIRATORY VIEW EXPIRATORY VIEW

Pneumothorax CT SCAN

Pleural Effusion Meniscus sign

Infrapulmonary Effusion Stomach NORMAL EFFUSION Stomach

Pleural Effusion DECUBITUS VIEW

Large Right Pleural Effusion PA VIEW Chest X-ray CT SCAN

Interstitial and Airspace Edema Pulmonary Edema Interstitial and Airspace Edema

Interstitial Pulmonary Edema

Vascular Indistinctness Normal Interstitial Edema

Vascular Indistinctness Normal Abnormal

Interstitial Pulmonary Edema Kerley “B” Lines Peribronchial cuffing Hila look larger Vessels are ill-defined Upper lobe vessels are larger Fluid in fissures Small pleural effusions

Interstitial Pulmonary Edema NORMAL INTERSTITIAL EDEMA

Minimal Changes Lateral View NORMAL INTERSTITIAL EDEMA

Interstitial Edema PA View Lateral

Pulmonary Edema

Interstitial Edema Kerley “B”s

Kerley “B” Lines CT SCAN

Airspace Edema

Airspace and Interstitial Edema Pulm Edema Normal

Airspace Edema Patient Supine

Airspace Edema

Airspace Edema Consolidation is bilateral Consolidation is symmetrical Consolidation is “gravity dependent” Consolidation changes day to day

Chronic Obstructive Lung Disease

Emphysema

Characteristics of Emphysema Increased Lung Volume Flattened Diaphragms Increase in Retrosternal Airspace Barrel chest Small Vessels Small, narrow cardiac silouhette

Emphysema CT Scan

Emphysema - CT Bulla Black holes

Bronchiectasis

Bronchiectasis Signet Ring Sign

Pneumonia

Radiological Patterns of Pneumonia Lobar pneumonia Bronchopneumonia Interstitial pneumonia

Lobar Pneumonia Involves single area, usually a lobe Bloodborn pathogen Unilateral Commonest pathogen:Strept Pneumonia RLL PNEUMONIA

LLL Pneumonia

Right Lower Lobe Pneumonia

Lobar Pneumonia

Bronchopneumonia Central bronchi involved Patchy bilateral disease Asymetrical Peribronchial Cuffing Commonest pathogen: Staph aureus

Bronchopneumonia

Bronchopneumonia CT SCAN

Interstitial Pneumonia Involves interstitial space, not airways “ground glass” appearance Bilateral, symetrical If severe, involves airspace Commonest pathogen: PCP, mycoplasma

Interstitial Pneumonia NORMAL

Interstitial Pneumonia Normal Abnormal

Interstitial Pneumonia

ABDOMEN Soft Tissue Findings

Normal Abdomen Liver Spleen Psoas muscle Kidney Outlined by fat

Hepatosplenomegally ABNORMAL NORMAL

Splenomegally

Pancreatitis Psoas muscle ABNORMAL SUPINE NORMAL SUPINE

Pancreatitis Psoas muscle CT Scan PANCREATITIS NORMAL

Properitoneal Fat Line Large bowel Normal fat line Normal Abdomen

Separation of bowel and fat line by fluid Ascites Separation of bowel and fat line by fluid Paracolic gutter

Ascites Fluid Fluid CT SCAN PELVIS CT SCAN UPPER ABDOMEN

ABDOMEN Calcifications

Renal Calculi Renal Stones

Renal Calculus

Renal Calculus on Intervenous Pyelogram Normal DELAYED EXCRETION OF CONTRAST ON IVP

Renal Calculus on Intervenous Pyelogram (IVP) Obstructed Ureter POST VOID DILATED COLLECTING SYSTEM

Renal Calculus on CT Scan Dilated Renal Pelvis Bladder Renal Calculus Renal Calculus

Stone Pelvis in Distal Ureter

Abdominal Aortic Aneurysm

Abdominal Aortic Aneurysm

Ruptured AAA Blood Aorta Aorta

Gallstones Supine Upright

Gallstone Stone Acoustic shadow ULTRASOUND

Acoustic Shadowing on Ultrasound SOFT TISSUE POLYP CALCIFIED GALLSTONE

Appendicolith Supine Upright

Bowel Gas Distribution ABDOMEN Bowel Gas Distribution

SMALL BOWEL FOLLOW-THROUGH Normal Small Bowel SMALL BOWEL FOLLOW-THROUGH

Normal Large Bowel BARIUM IN LARGE BOWEL

Large Bowel Rectum Fecal Impaction Constipation

Dilated large and small bowel Generalized Ileus Supine Dilated large and small bowel No air/fluid levels Decubitus

Localized Ileus Supine Upright

Small Bowel Obstruction Air-fluid levels UPRIGHT VIEW SUPINE VIEW

Small Bowel Obstruction NORMAL DILATED SMALL BOWEL

Small Bowel Obstruction SUPINE VIEW UPRIGHT VIEW

SUPINE VIEW

Free Air and SBO UPRIGHT VIEW DECUBITUS VIEW

Free air and fluid CT SCAN

Can see both sides of bowel wall Free Air Normal Can see both sides of bowel wall (Rigler’s Sign)

Free Air Supine Decubitus

Large Bowel Obstruction SUPINE VIEW UPRIGHT VIEW

SUPINE VIEW – DISTENDED LOOP ARISING OUT OF PELVIS Sigmoid Volvulus SUPINE VIEW – DISTENDED LOOP ARISING OUT OF PELVIS

Sigmoid Volvulus DECUBITUS VIEW UPRIGHT VIEW

Volvulus CECAL VOLVULUS Associated with SBO SIGMOID VOLVULUS Associated with LBO

Thumbprinting BARIUM ENEMA SUPINE VIEW

Causes of Thumbprinting Enteritis or colitis Infarction Hemorrhage into bowel wall SUPINE VIEW

Bowel Infarction Air in Portal Vein Air in Bowel Wall SUPINE VIEW

Bowel Infarction Air in Portal Vein Air in Bowel Wall CT SCAN CT SCAN

Thank You!