7. INTERPRETATION OF THE ABNORMAL FILM.pptx

INTERPRETATION OF THE ABNORMAL FILM

1. INTERPRETATION OF THE ABNORMAL FILM Dr Abrham J.(MD) 1

2. Helpful radiological signs The silhouette sign is the loss of an interface by adjacent disease and permits localization of a lesion on a film by studying the diaphragm, cardiac and aortic outlines 2

3. Cervicothoracic sign Hilum overlay sign 3

4. Consolidation is due to replacement of air in the alveoli by fluid , or occasionally tissue, resulting in areas of confluent homogeneous shadowing Patent bronchi and some small airways are often still visible as linear lucencies , when surrounded by fluid - filled alveoli; this sign is called an air bronchogram 4

5. The air bronchogram Causes Common Expiratory film Consolidation Pulmonary oedema Hyaline membrane disease Rare Lymphoma Alveolar cell carcinoma Sarcoidosis Fibrosing alveolitis Alveolar proteinosis ARDS Radiation fibrosis 5

6. Air-space ( acinar /alveolar) pattern Pulmonary oedema * Cardiac Non-cardiac Fluid overload Hypoalbumenaemia Uraemia Shock lung (ARDS) Fat embolus Amniotic fluid embolus Drowning Hanging High altitude Blast injury Oxygen toxicity Aspiration ( Mendelson's syndrome) Malaria Inhalation of noxious gases Heroin overdose Drugs (e.g. nitrofurantoin ) Raised intracranial pressure/head injury Infections Localised Generalised , e.g. Pneumocystis *, parasites, fungi Neonatal Hyaline membrane disease Aspiration Alveolar blood Pulmonary haemorrhage , haematoma Goodpasture's syndrome* Pulmonary infarction Tumours Alveolar cell carcinoma* Lymphoma, leukaemia Metastatic adenocarcinoma Miscellaneous Alveolar proteinosis * Alveolar microlithiasis Radiation pneumonitis Sarcoidosis Eosinophilic lung Polyarteritis nodosa Mineral oil aspiration/ingestion Drugs Amyloidosis Wegener's granulomatosis Churg –Strauss syndrome Allergic bronchopulmonary aspergillosis 6

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8. Reticular/ interstitial shadowing This is produced by thickening of the tissues around the alveoli, the lung interstitium , and visualized as a fine or coarse branching linear pattern. Typical conditions giving rise to this type of shadowing are lung fibrosis and pneumoconiosis. 8

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10. Nodular shadowing Small, discrete spherical opacities Causes : miliary tuberculosis; pneumoconiosis; sarcoidosis ; neoplastic : miliary carcinomatosis from thyroid, melanoma, etc. 10

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12. Pneumonia Primary pneumonia Inflammation arising in a normal lung Secondary pneumonia Caused by: ● Occluded bronchus from bronchial carcinoma or foreign body ● Aspiration from pharyngeal pouch, oesophageal obstruction ● Underlying lung pathology: bronchiectasis , cystic fibrosis 12

13. Lobar pneumonia Inflammatory changes confined to a lobe, classically due to Streptococcus pneumoniae Bronchopneumonia Produces bilateral multifocal areas of patchy opacities 13

14. Radiological features not possible to diagnose the infecting agent from the type of shadowing increased density with inflammatory exudate and fluid occupying the alveolar space - consolidation with air bronchogram ) Consolidation may persist, often after the patient ’s symptoms have improved CT is not required for primary pneumonia, but allows assessment of complications 14

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16. Tuberculosis is a chronic infection caused by Mycobacterium tuberculosis 16

17. Radiological features Primary tuberculosis ● Area of peripheral pneumonic consolidation ( Ghon focus) with enlarged hilar / mediastinal glands (primary complex). This usually heals with calcification. ● Areas of consolidation, which may be small, lobar or more extensive throughout the lung fields. 17

18. Postprimary tuberculosis or reactive tuberculosis ● Patchy consolidation, especially in the upper lobes or apical segments of the lower lobes, often with cavitation ● Pleural effusions , empyema or pleural thickening ● Miliary tuberculosis : discrete 1 – 2mm nodules distributed evenly throughout the lung fields due to haematogenous spread ● Mediastinal or hilar lymphadenopathy is typically not a feature, except in acquired immune deficiency syndrome (AIDS) patients As healing progresses, features that may be recognized are: fibrosis and volume loss; calcified foci; tuberculoma (a localized granuloma often containing calcification); pleural calcification. 18

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20. Bronchiectasis is defined as a condition in which there is an irreversible dilatation of the bronchi. Causes ● Childhood infections , Aspergillosis,Bronchial obstruction, ● Congenital: Kartagener ’ s syndrome ( dextrocardia , sinusitis and bronchiectasis ) ,Cystic fibrosis 20

21. Radiological features The chest film may be entirely normal Bronchiectasis is commonest at the lung bases and chest X - ray may reveal the following features ● Cylindrical bronchiectasis : dilated bronchi may be visible as parallel lines (representing the bronchial walls) radiating from the hilum towards the diaphragm ● Cystic bronchiectasis : terminal dilatation may be visualized as cystic or ring shadows, sometimes with fluid levels ● Pneumonic consolidation ● Fibrotic changes- traction bronhiectasis 21

22. CT ● bronchi visible peripherally; ● bronchus larger in diameter than the adjacent pulmonary artery branch 22

23. Pleural effusion Pleural effusion, a fluid collection in the space between the parietal and visceral layers of the pleura, usually contains serous fluid , but may have different contents Haemothorax : Blood, usually following trauma Empyema : Purulent fluid from extension of pneumonia or lung abscess Chylothorax : Chyle from thoracic duct rupture or from malignant invasion Hydropneumothorax : Fluid and air 23

24. Radiological appearances in the erect position, gravitates to the lower Initially the fluid accumulates in the posterior, then the lateral costophrenic space Chest X - ray: homogeneous opacification ● loss of the diaphragm outline ● no visible pulmonary or bronchial markings; ● concave upper border with the highest level in the axilla . volume loss - retracts towards the hilum,mediastinal shift to the opposite side 24

25. Subpulmonic effusion Caused by fluid accumulating between the diaphragm and the inferior part of the lung The upper margin of the shadow of the fluid runs parallel to the diaphragm and on the PA chest film mimics a high diaphragm Loculated effusion Fluid can loculate in the fissures or against the chest wall Ultrasound is a highly sensitive CT may also demonstrate pleural effusions and visualize underlying abnormalities 25

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27. Pneumothorax A pneumothorax occurs when air enters the pleural cavity via a tear in either the parietal or visceral pleura; the lung subsequently relaxes and retracts to a varying extent towards the hilum Causes ● latrogenic ● Spontaneous ● Trauma: stab wounds, rib fractures ● Pre - existing lung disease: emphysema, cystic fibrosis or interstitial lung disease 27

28. Radiological features Pneumothorax is best demonstrated on an underpenetrated chest film ● Lung edge: a thin white line of the lung margin, the visceral pleura - Absent lung markings between the lung edge and chest wall ● Mediastinal shift: when a tension pneumothorax develops 28

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30. Hilar lymphadenopathy cause enlargement of the hilar shadows appearing as well - defined , lobulated masses Causes Bilateral Sarcoidosis : commonest cause Lymphoma Tuberculosis Metastases Unilateral Bronchial carcinoma Lymphoma Tuberculosis 30

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32. Lung abscess is a localized, necrotic, cavitating lesion due to a pyogenic infection Secondary abscess formation may occur from aspiration Radiological features may initially start as an area of pneumonic consolidation ( especially Staphylococcus aureus or Klebsiella pneumoniae ) with subsequent development of cavitation A fluid level is often noted in the abscess 32

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34. Differential diagnosis of a cavitating lesion Infections Staphylococcus Klebsiella Tuberculosis Histoplasmosis Amoebic Hydatid Paragonimiasis Fungal Malignant Primary Secondary Lymphoma Abscess Aspiration Blood-borne Pulmonary infarct Pulmonary haematoma Pneumoconiosis Pulmonary massive fibrosis Caplan's syndrome Collagen diseases Rheumatoid nodules Wegener's granulomatosis Developmental Sequestrated segment Bronchogenic cyst Congenital cystic adenomatoid malformation Sarcoidosis Bulles , blebs Traumatic lung cyst Pneumalocele 34

35. Collapse Signs of lung collapse Direct Opacity of the affected lobe(s); Crowding of the vessels and bronchi within the collapsed area, and Displacement or bowing of the fissures Indirect Compensatory hyperinflation of the normal lung or lobes resulting in an increase in transradiancy with separation of the vascular marking; Displacement of the mediastinal structures toward the affected side Displacement of the ipsilateral hilum which changes shape 35

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40. Bronchial carcinoma is a common primary tumour Small cell lung cancer ( SCLC) and Non - small cell lung cancer (NSCLC ) Adenocarcinoma , Squamous cell and Large cell carcinoma 40

41. Radiological features Plain Chest Film ● Lobulated or spiculated mass but sometimes with a smooth outline. ● Associated hilar gland enlargement, pleural effusion, areas of collapse or consolidation . ● Cavitation found in 15% with central air lucency , an air/fluid level and a wall of variable thickness . - Squamous carcinomas frequently cavitate . 41

42. CT chest and upper abdomen ● Assesses spread and determines operability --metastatic spread into the mediastinal lymph nodes, chest wall, liver or adrenals MRI is more accurate in defining mediastinal and vascular invasion PET or PET/CT scan to determine metastatic spread 42

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45. Malignant Primary nodule Plasmacytoma Alveolar cell carcinoma Lymphoma Secondary nodule Benign Adenoma Hamartoma Connective tissue tumours Granuloma Sarcoidosis Tuberculosis Histoplasmosis Paraffinoma Impacted mucus Amyloidosis Intrapulmonary lymph node Pleural Fibroma Tumour Loculated fluid Infection Round pneumonia Abscess Hydatid Amoebic Fungi Parasites Congenital Bronchogenic cyst Sequestrated segment Congenital bronchial atresia AVM Non-pulmonary Skin and chest wall lesions Artefacts Pulmonary infarct Pulmonary haematoma Collagen diseases Rheumatoid arthritis Wegener's granulomatosis Differntial diagnosis of solitary pulmonary nodule 45

46. Pulmonary metastases is a common complication of primary neoplastic disease Tumours of the breast, renal tract, testis, gastrointestinal tract, thyroid and bone are often the primary source Radiological features can be seen on either plain films or CT Lungs usually appear as well - defined , multiple, round opacities of differing sizes in the lung fields Cavitation is occasionally present, usually indicating metastases from squamous cell carcinoma 46

47. Pleura often from breast carcinoma, and may be visualized as mass lesions pleural effusion - the most common manifestation Lymph nodes CT is highly accurate Lymphangitis carcinomatosa –lymphatic congestion with a linear pulmonary pattern radiating outwards from the hilar glands, septal lines and pleural effusions Local invasion Pericardium ; superior vena cava compression or obstruction; phrenic nerve paralysis Skeletal system: ribs, thoracic spine, shoulder 47

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