Surgery_XRays basic xray findings in general surgery mbbs.pptx

Surgery basic xrats

1. X ray in view of surgeons DR B SATHYA PRIYA M.S

2. HOW TO READ AN X-RAY Properties of an x-ray image It is an grey scale It is summations of shadows It is two dimensional representation of a three dimensional concept It is a static representation of a dynamic disease process interpret with history, laboratory findings, serial image findings

3. HOW TO READ AN XRAY IMAGE Elements of visual search Elements of detection Elements of interpretation A thorough knowledge of anatomy pathology, Pathoanatomy pathophisiology of the disease process with statistical guidance is essential to come to a reasonable diagnosis

4. BASIC DENSITIES Air = black Fat = dark grey Soft tissue/fluid = light grey Bone/calcification = white Metal = intense white

5. CHEST X-RAY PA VIEW Commonest of all x-ray investigations performed in the department It is considered a routine but in fact it is the most essential first x-ray examination Most of the diseases systemic pulmonary or cardiac can be diagnosed by a glimpse through this window

6. INDICATIONS In All Diseases Of The Chest ( Chestwall Lung Heart & Mediastinum ) To The Check The Correct Placement Of Tubes, Electrodes And Other Monitoring Devices Mass Minature Screening Of Communicable Diseases Like Tb Pyrexia Of Unknown Origin Preoperative Assesment Before General Anesthesia For Immigration And Health Care Screening In Other Systemic Or General Diseases With Suspected Lung Involvement

7. NOTE CHANGE IN HEART SIZE AND VASCULARITY DUE TO EXPIRATION. Technical Aspects of chest x-ray Inspiration Expiration

8. Penetration DID YOU SEE THE NODULE

9. Rotation DISTORTED MEDIASTINUM DUE TO TORTOUS AORTA AND ROTATION.

10. Orientation PA AP . The cardiac border or silhouette will appear larger on an AP radiograph due to the magnification effect of the more anteriorly located heart relative to the film

11. Angulation

12. Normal Chest X-ray P-A view Male Female (breast shadow)

13. Chest trauma Left costo-phrenic angle is obliterated Left haemothorax

14. Chest trauma transverse air-fluid level Haemopneumothorax

15. Pneumothorax collapsed right lung Chest trauma

16. Right tension pneumothorax Chest trauma This X-ray should not have been done because a tension pneumothorax is diagnosed clinically and should be drained immediately with no waste of time

17. Tumours bronchial cancer solitary metastasis adenoma lung cyst lung abscess …….. coin shadow

18. Subphrenic Air perforated duodenal ulcer. Less common causes include perforated other viscera (stomach, small intestine, colon), subphrenic abscess with gas-forming bacteria, shortly after abdominal operations where air enters through the wound during surgery. Crescent sign

19. Subphrenic Air Unfortunately this radiographic sign is present in only 60% of cases of DU perforation

20. Contrast study Normal Barium swallow Barium swallow is a contrast radiological test to visualize the oesophagus . Barium, which is a radio-opaque material is prepared in a paste form. The thickness of this paste allows the contrast material to go down the oesophagus at a slow-enough rate to take radiographic shots

21. Normal Barium meal in standing position. This is known because air in the stomach is present at the fundus (gastric air bubble) Barium meal is a contrast radiological test to visualize the stomach. Barium, which is a radio-opaque material is prepared in a thin emulsion form. Contrast study Normal Barium meal

22. Pharyngeal Diverticulum Barium swallow showing an oesophageal diverticulum Diverticulum oesophagus

23. Smooth narrowing of lower oesophagus at the level of diaphragm Markedly dilated oesophagus Gastric air bubble is commonly absent because retained fluid in t he oes ophagus acts as a water seal that prevents entry of swallowed gas into the stomach Achalasia of cardia

24. Oesophageal Cancer Barium swallows showing oesophageal carcinomas . The next step is endoscopic biopsy, followed by staging

25. Benign Oesophageal Stricture Barium swallows showing oesophageal stricture . This patient gives a history of ingesting a corrhosive material. The key to diagnosis is the history

26. cardia hernia reflux diaphragm Barium meal in Trendlenberg’s position Sliding hiatus hernia with gastro- oesophageal reflux Oesophageal Hiatus Hernia

27. Chronic Duodenal Ulcer Barium meals showing chronic duodenal ulcers ulcer Trifoliate deformity

28. Chronic Gastric Ulcer Barium meals showing Chronic gastric ulcers on the lesser curvature, which is the typical position of a benign ulcer. Endoscopy and multiple biopsies are, nevertheless, essential to rule out malignancy.

29. Gastric Cancer Barium meal showing an irregular filling defect in the upper part of lesser curve that is suggestive of gastric cancer

30. Barium meal examinations that show irregular narrowing of the pylorus that are caused by gastric cancer . This is the commonest site of carcinoma of the stomach Gastric Cancer

31. Barium meal that shows irregular diffuse narrowing of the stomach Linitis plastica This is a rare type of gastric cancer Gastric Cancer

32. Others Plain Chest P-A view of a child The left side of chest is occupied with bowel loops and the mediastinum is pushed to the right side This is congenital diaphragmatic hernia

33. Others Plain Chest P-A view Common causes of a wide superior mediastinum are retrosternal goitre , lymph node enlargement and thymus tumours In a trauma victim it may be caused by rupture of aortic arch Chest tube

34. Abdomen

35. checklist Exposure Rotation Diaphragm + above and below Liver Spleen Kidney Psoas shadow Pelvis Calcification Abnormal bowel gas pattern / extraluminal air Soft tissue mass Visualized bones

36. liver RK LK UB Psoas line

37. Side Marker

38. NORMAL PLAIN X-RAY OF ABDOMEN Normally the stomach and colon contain gas that can show here, particularly if the patient is not well prepared Normally the small intestine contains no gas (or a very minimal amount). Small bowel gas shadow may normally show in one or two very small loops at most Colon gas

39. In fact this is a double contrast Barium Enema whereby the patient evacuates the barium and air is then pumped in. This method improves accuracy of detecting minor mucosal changes NORMAL BARIUM MEAL

40. Plain X-ray for Intestinal Obstruction Commonest site of mechanical obstruction Its commonest cause in adults is adhesions that may follow intra-abdominal surgery

41. Plain X-ray for Intestinal Obstruction Jejunum Ileum multiple air-fluid levels

42. Plain X-ray for Intestinal Obstruction High small bowel obstruction (diagram) Jejunum

43. Sigmoid colon obstruction Colonic haustrations Unlike the mucosal pattern of jejunum colonic haustrations are indentations that do not cross the whole diameter of the colon to the other side

44. Sigmoid volvulus Omega loop

45. Intussusception colon Head of intussusception claws colon At surgery reduction of intussusception is done by pushing its head backwards never by pulling on the ileum Barium enemas in infants showing the characteristic “claw sign ”

46. Hirschsprung’s Disease colon Barium enema in a child showing a narrow segment of distal bowel) and a. Hirschsprung’s disease aganglionic segment proximal dilated colon

47. Barium enema showing the characteristic persistent irregular filling defect of Right Colon Cancer caecum

48. Colon Cancer of Hepatic Flexure Cancer sigmoid and rectosigmoid junction

49. Inflammatory Bowel Disease Barium enemas showing narrowing and loss of haustrations of colon. These are examples of ulcerative colitis

50. Inflammatory Bowel Disease Dilated small intestine Narrow segment Barium meal follow through showing narrowing of terminal ileum and proximal dilatation. This is a case of ileo-caecal Crohn’s disease

51. Colonic Diverticula Remember that Barium enema is contraindicated in acute diverticulitis or acute exacerbation of ulcerative colitis

52. Colonic Polyps Barium enema showing multiple filling defects of colonic polyps

53. Normal IVU Course of ureter : Abdominal part starts at transverse process of L2 then descends over transverse processes of remaining lumbar vertebrae Iliac part lies medial to sacro -iliac joint Pelvic part descends down to ischial spine then turns downwards and medially to bladder base

54. IVU BILATERAL RENAL AND URETERIC DUPLICATION

55. HYDRONEPHROSIS IVU Right side early hydronephrosis and hydroureter

56. HYDRONEPHROSIS IVU Left hydroureter and hydronephrosis possibly caused by a stone in lower ureter . Plain UT should be checked to look for this stone ? stone

57. Stones Differential diagnosis includes gall stone. A lateral view shows that the shadow lies posteriorly on the spine. This is a right renal stone

58. Stones Multiple stones raise suspicion of hyperparathyroidism Hyperparathyroidism is a disease of Bones Stones Abdominal groans Psychic moans Fatigue overtones

59. Stones Right kidney stag-horn stone These are phosphate stones that are usually related to infection and commonly affect function of the affected kidney Plain UT IVU

60. Stones Plain UT IVU Left ureter stone with left hydronephrosis and hydroureter

61. Stones Plain X-rays of pelvis showing radio-opaque shadows in the region of the urinary bladder Urinary bladder stones

62. Plain X-ray Only 15% of GB stones are radio-opaque. The majority are radiolucent. This is in contrast with urinary stones that are mostly opaque

63. Oral Cholecystography As most GB stones are radiolucent they appear as filling defects This test is rarely used in modern practice as it has been superceded by U/S

64. If the CBD is opened during surgery to look for and remove stones it should be closed over a T-tube. About 10 days after the operation T-tube cholangiography is done by injecting a contrast material through this tube. Look for: Filling defects in bile duct (stones) Free entry of contrast to the duodenum CBD Duodenum T-tube In this case there is no abnormality and the tube can be pulled out safely. The resulting hole in bile duct closes spontaneously within 2 days Normal T-tube cholangiogram

65. T-tube Cholangiography duodenum duodenum Missed stone Missed stone T-tube Missed stones in common bile duct discovered by T-tube cholangiography

66. ERCP Endoscopic Retrograde CholangioPancreatography Radiographic diagnosis is CBD stones Sphincterotomy and stone removal can be done in the same session. Large stones require fragmentation before removal Dilated CBD stones

67. ERCP CBD is transversely cut at level of obstruction. This is possibly a malignant obstructio In jaundiced patients ERCP should be preceded by U/S examination and by checking prothrombin time and correcting it whenever needed Dilated bile ducts Obstruction ? malignant

68. PTC catheter Examples of PTC that show the level of obstruction and proximal dilatation of intrahepatic bile ducts

69. Thank you