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1. X-RAYS DR.G.S.R.HAREESH

2. X-RAYS Plain X- Rays Contrast X-rays Barium swallow Barium meal Barium enema Intravenous urography Endoscopic retrograde cholangiopancreaticography T-tube cholangiogram Percutaneous transhepatic cholangiography

3. X-Ray Reading Plain / Contrast View or Orientation Part of body Systematic examination (ABCDE)

4. ABCDE A - A is for Air in the wrong place Look for pneumoperitoneum & pneumoretroperitoneum Look for gas in the biliary tree and portal vein B - B is for Bowel Look for dilated small and large bowel Look for a volvulus Look for a distended stomach Look for a hernia Look for evidence of bowel wall thickening

5. ABCDE C - C is for Calcification Look for clinically significant calcified structures such as renal calculus, nephrocalcinosis , pancreatic calcification and an abdominal aortic aneurysm (AAA ), calcified gallstones Look for clinically insignificant calcified structures such as costal cartilage calcification, phleboliths , mesenteric lymph nodes, calcified fibroids, prostate calcification and vascular calcification Look for a foetus (females )

6. ABCDE D - D is for Disability (bones and solid organs) Look at the bony skeleton for fractures and sclerotic/lytic bone lesions Look at the spine for vertebral body height, alignment, pedicles and a ‘bamboo spine’ Look for solid organ enlargement E - E is for Everything else Look for evidence of previous surgery and other medical devices Look for foreign bodies Look at the lung bases

7. Plain X-Rays Pneumoperitoneum Small Bowel Obstruction Sigmoid Volvulus Renal Caluculus Bladder Calculus Pancreatic Calculi Canon Ball Secondaries

8. Contrast X-rays Barium Swallow Achalasia Ca Esophagus Barium Meal GOO Barium Enema Ca Colon IVP

9. PNEUMOPERITONEUM Miss it and the patient may die Bilateral dark crescents of gas under both domes of diaphragm Erect posture Left lateral decubitus 1 ml of air is more than enough

10. Signs of pneumoperitoneum Double wall sign ( RIGLER’S sign ) Football sign – centrally placed intraperitoneal free air Dome sign Cupola sign of air under the central diaphragm Silver’s sign – visualization of falciform ligament Continuous diaphragm sign Lucent liver sign – air overlying or outlining liver Doges cap sign – triangle of air outlinig morrison’s pouch Inverted V sign - air in umbilical ligaments

11. Visualization of both the outer and inner walls of a bowel loop is known as Rigler's sign

12. Causes of pneumoperitoneum With peritonitis Perforation of a hollow viscus , peptic ulcer most often Intestinal obstruction Ruptured diverticular disease Penetrating injury – gun shot , knife wounds Ruptured inflammatory bowel disease( megacolon ) Colonic infections (typhoid)

13. Causes of pneumoperitoneum Without peritonitis Post laparotomy Post laparoscopy Jejunal diverticulosis Steroids Tracking from chest ( pneumothorax ) Peritoneal dialysis Vaginal insufflation (douching, hysteroscopy) Pneumatosis coli

14. Conditions mimicking pneumoperitoneum Intestine between liver and diaphragm— Chilaiditi's syndrome Subphrenic abscess Curvilinear atelectasis in the lung Subdiaphragmatic fat Diaphragmatic irregularity Cysts in pneumatosis intestinalis Meteorism Distended gastric fundus

15. Curvilinear atelectasis in the lung

16. Chilaiditi's syndrome

17. Meteorism

18. Fat

19. Peptic Ulcer Perforation Aetiology Clinical features Stages Investigation Management Resuscitation Surgery

20. Fluid levels are common in normal people, and they usually lie in the colon. Three to five fluid levels less than 2.5 cm in length may be seen, particularly in the right lower quadrant, without any evidence of intestinal obstruction or paralytic ileus . More than two fluid levels in dilated small bowel ( calibre greater than 2.5 cm) are said to be abnormal, and usually indicate Paralytic ileus or Intestinal obstruction

21. The causes of SBO are myriad, but can be largely divided into Mural lesions tumour , stricture due to Crohn's disease, irradiation, ischaemia Luminal bezoar , gallstone, Ascaris lumbricoides bolus, intussusception Extrinsic adhesions, hernia, volvulus , abdominal malignancy

22. Distinction between small- and large-bowel dilatation Dilated small-bowel loops are usually more numerous and arranged centrally in the abdomen. The loops show a small radius of curvature and rarely exceed 5 cm in diameter. The presence of solid faeces is the only reliable sign that the loop is large bowel. The other signs can be misleading. The small-bowel folds or valvulae conniventes form thin, complete bands across the bowel gas shadow, prominent in the jejunum but becoming less marked as the ileum is reached. The valvulae conniventes are much closer together than colonic haustra and become thinner when stretched.

23. Sigmoid volvulus The inverted U-shaped loop is usually massively distended Commonly devoid of haustra , an important diagnostic point. The ahaustral margin can often be identified overlapping respectively the lower border of the liver shadow ( the liver overlap sign ), the haustrated , dilated descending colon ( the left flank overlap sign ) the left side of the pelvis ( the pelvic overlap sign ). The top of the sigmoid volvulus usually lies very high in the abdomen ( above the level of T10 ) with its apex on the left side.

24. Signs Grossly distended loop of sigmoid colon Coffee bean sign Air – fluid ratio > 2:1 Lack of haustra Apex above 10 th thoracic vertebra Liver overlap sign Left flank overlap sign Pelvis overlap sign Bird of prey /twisted bird beak appearance

25. Doubt about the diagnosis on the plain radiographs Contrast enema

26. Contrast enema Features seen at the point of torsion include a smooth, curved tapering of the colonic lumen, like a hooked beak ( the bird of prey sign ) the mucosal folds often show a ‘screw’ pattern at the point of twist

27. What are the D/D of a radiopaque shadow in this region? Kidney stone Gallstones Pancreatic calculi Foreign body Fecolith Phleboliths calcified lymph node calcified renal tuberculosis calcified adrenal gland chip fracture of a transverse process of vertebra or calcification of costal cartilage

28. What are the important causes of cannon ball shadows in chest X-ray ? Metastasis Benign lesion Fungal infection— Histoplasmosis , coccidioodomycosis , aspergillosis . Parasitic infection—Filarial infection, hydatid disease. Sarcoidosis . Wegener’s granulomatosis . Rheumatoid nodules.

29. Contrast Films Barium Swallow Barium Meal Barium Enema IVP

30. Barium Studies Barium studies can demonstrate GI abnormalities in three ways Mucosal relief views of the collapsed or partially collapsed lumen obtained with a small volume of barium. particularly useful for showing abnormalities involving the submucosa , such as esophageal varices . Single-contrast views of the filled lumen obtained with a large volume of low-density barium These views enable visualization of contour abnormalities, strictures, and large polypoid defects. Double-contrast views obtained after the mucosal surface has been coated with a thin layer of high-density barium and the lumen has been distended with gas These views enable visualization of subtle mucosal lesions, such as the early changes of inflammatory bowel disease and early neoplastic lesions

31. Barium suspensions for single-contrast studies should be of moderate density (50%-100% w/v) when not diluted. For the double-contrast examination, we use high-density 250% w/v barium