1. Internal Medicine Clerkship
Abdominal and Chest X-Rays
Internal Medicine Clerkship

2. Recognize this image?
First x ray ever shot by Wilhelm Konrad Roentgen in 1896

3. CXR reading
Before starting it is very useful to develop a sense of -what is normal
Interpreting a chest x ray is a stepwise systematic study of the film
When looking at CXR it is best to look at PA and lateral views...you must see abnormality in both to make sure that pathology really exists

4. Steps to follow Exposure – underexposed or overexposed
Soft tissues – obvious masses, sub -cutaneous air, calcifications
Bones – size, contour, obvious abnormalities, bone density, joints
Trachea – midline or shifted
Diaphragm, pleural space
Heart borders, vasculature
Lung fields
Other – hardware (e.g. lines, tubes, etc)

5. CXR reading
The right heart border is formed by right atrium and is obscured by the medial segment of the right middle lobe
The left heart border is formed by the left ventricle and is obscured by lingular process of the LUL

6. Normal Chest X ray
1. Trachea. 2. Carina. 3. Right atrium. 4. Right hemi-diaphragm. 5. Aortic knob. 6. Left hilum. 7. Left ventricle. 8. Left hemi-diaphragm (with stomach bubble). 9. Retrosternal clear space. 10. Right ventricle. 11. Left hemi-diaphragm (with stomach bubble). 12. Left upper lobe bronchus.

7. CXR reading
The trachea is midline but may be deviated to the right mildly from a tortuous aorta
The costophrenic angles should be sharp on both views, except in patients with severe emphysema (can be flattened)

8. Bony Structures

9. Heart size on PA film should be less than or equal to 50% of the widest diameter of the thoracic cage

10. Find the Anomaly

11. Aorta

12. The aortic arch or “knob” is above the left hilum

13. Hilar opacities are predominantly due to PA and should be symmetric in size and density.

14. Vasculature

15. Diaphragm not equal on both sides (R>L by 1.5-2.0 cm)

16. What the hell is that??
A sword swallower

17. The minor fissure is on the right, separating the right upper lobe from the right middle lobe

18. Breast shadows

19. RUL

20. RML

21. RLL

22. LLL

23. LUL with Lingula

24. Lingula

25. LUL (without the lingula)

26. Find the Anomaly
Left upper lobe scarring with hilar retraction with less prominent scarring in right upper lobe as well. Findings consistent with previous tuberculosis infection in an immigrant from Ecuador

27. Lines..

28. Find the Anomaly
CXR demonstrates reticular nodular opacities bilaterally with small lung volumes consistent with usual interstitial pneumonitis (UIP) on pathology. Clinically, UIP is used interchangeably with idiopathic pulmonary fibrosis (IPF).

29. Name the condition
Sarcoid—CXR of stage I (hilar lymphadenopathy without parenchymal infiltrates).

30. Name the condition
CXR reveals diffuse, bilateral alveolar infiltrates without pleural effusions, consistent with acute respiratory distress syndrome (ARDS). Note that the patient has an endotracheal tube (red arrow) and has a central venous catheter (black arrow).

31. What is the Diagnosis
Large right pneumothorax with near complete collapse of right lung. Pleural reflection highlighted with red arrows.

32. Find the Abnormality
Left upper lobe mass, which biopsy revealed to be squamous cell carcinoma.

33. Case 1...30 year old with cough and fever

34. Answer...Superior RLL infiltrate

35. Case year old with SOB

36. Answer…CHF CHF… cardiomegaly cephalization prominent hilum
Angles blunted…may see pleural effusions

37. Congestive Heart Failure
Mild congestive heart failure. Note the Kerley B lines (black arrow) and perivascular cuffing (yellow arrow) as well as the pulmonary vascular congestion (red arrow).

38. Case 3…25 yo with CP and SOB

39. Answer…Pneumothorax
Symptoms...Sudden shortness of breath, dry coughs, cyanosis and pain felt in the chest, back and/or arms
absence of audible breath sounds and hyperresonance to percussion of the chest wall is suggestive of the diagnosis
Small pneumothoraces often are managed with no treatment other than repeat observation, Larger pneumothoraces may require chest tube placement

40. Case 4…44 yo with DOE

41. Answer…Pleural effusions
Healthy individuals have less than 15 ml of fluid in each pleural space
Chest films acquired in the lateral decubitus position are more sensitive than an upright, and can pick up as little as 50 ml of fluid
At least 300 ml of fluid must be present before upright chest films can pick up signs of pleural effusion (e.g., blunted costophrenic angles)
Once there is more than 500 ml, there are usually detectable clinical signs in the patient...decreased movement of the chest, dullness to percussion over the fluid, diminished breath sounds, decreased vocal fremitus and resonance, pleural friction rub, and egophony.

42. Normal AXR

43. Densities in AXR Black: Gas White: Calcification Grey: Soft Tissues
Dark Grey: Fat
Bright White: Metallic objects

44. Assessing the film Max 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 cecum is not dilated unless wider than 80mm
Large and small bowel may be distinguished by looking at bowel wall markings
The haustra of the large bowel extend only a third of the way across the bowel from each side
The valvulae conniventes of the small bowel tranverse the complete distance

45. Bowel Wall Markings

46. Extra-luminal Air Extra-luminal Gas:
When a bowel is obstructed, or any other gas containing structure perforates, its contained gas becomes extra-luminal. Extra-luminal gas is never normal, but may be seen following intra-abdominal surgery or endoscopic retrograde cholangio-pancreatography (ERCP).
Extra-luminal gas is seen on an erect AXR

47. Calcification
Pancreatic Calcification Gallstones

48. Soft Tissue
Soft tissues represent most of the contents of the abdomen and feature heavily in the AXR
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.

49. Splenomegaly

50. Foreign Objects
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

51. Foreign Objects Sterilization and Surgical Clips
Foreign body per rectum

52. Case 1...
This 67 year-old women presented to the surgical ward with a distended abdomen and vomiting

53. Answer…SBO
Multiple dilated loops of small bowel within the central abdomen, gas is not seen in the large bowel, no evidence of hernia or gallstone to suggest potential cause of the dilated loops
These findings are consistent with a small bowel obstruction
The three most common causes of SBO:
Surgical adhesions
Hernias
Intraluminal masses eg, small bowel lymphoma or gallstones in gallstone ileus

54. Case 2...
This 71 year-old gentleman visits his PCP complaining of blood in his urine. He has had a number of UTI’s in recent years

55. Answer…Bladder Calculi
Two rounded radio-opacities measuring 4cm within the pelvis
Both opacities are smooth in outline, laminated in nature, have the same density as bone and project over the bladder
No other renal tract calcification
Given the size of these stones and history of UTI’s these are bladder calculi
Bladder calculi are more common in those with a history of:
UTI’s
A neurogenic bladder
Bladder diverticulum

56. Case 3...
This patient was admitted with poor renal function

57. Answer…Nephrocalcinosis
Multiple areas of calcification project over the renal outlines bilaterally
The calcification is within the medulla of the renal parenchyma
The bones are normal in appearance
These findings are consistent with nephrocalcinosis…
Nephrocalcinosis may eventually result in acute obstructive uropathy or chronic obstructive uropathy, leading to eventual kidney failure
The disorder is often discovered when symptoms of renal insufficiency/renal failure, obstructive uropathy, or urinary tract stones develop

58. THE END