Diagnostics Radiology Exam 2 Flashcards
GI Contrast Agents
Barium (no bowel perf)
Gastrografin (water soluble) (for perf)
air used as a negative contrast agent
Barium and air = Double
GI contrast studies
Barium swallow
Upper GI (single/double)
Barium enema (single/double)
Contraindications to Barium Studies
large bowel obstruction (not by mount)
Elctrolyte imbalance
Perforation
Pharynx/Esophageal Imaging
modified barium swallow
Performed as videofluoroscopy
gold standard
at evaluating dysphagia
Barium swallow
Schatzki Ring
Esophageal ring stenosis typically
causing dysphagia
Very capable at blocking solid
food that is poorly chewed
Best view for esophogeal imaging
oblique view of a normal barium swallow shows the normal impressions made by the aortic arch, left mainstem bronchus, and (LA) left atrium on the esophagus.
Esophageal stricture
Stem from repeated bouts of
esophagitis with ulceration and
then subsequent fibrosis
(restriction)
Common sign of divertiucla and varices
Bad Breath
Esophageal Perforation
See following ETOH binges and
frequent vomiting
(Boerhaave’s syndrome)
Achalasia
Lower esophageal sphincter disfunction
“Bird’s Beak appearance”
Scleroderma
Collagen-vascular disease
characterized by diffuse fibrosis
Esophageal involvement occurs
in 75 to 87% of patients
Scleroderma difference from achalasia
no Birds beak LES constriction,
just widely patent dysfunctional LES
Types of esphogeal neospasms
Infiltrative Polypoid Annular stenotic Ulcerative Varicoid
Reasons for Abdominal XRay
- Abdominal Distention
- Suspected Bowel Perforation
- Suspected Bowel Obstruction
- Swallowed FB
- Diffuse Abdominal Pain
- Localize enteric tube or other device
- Screen for large kindey stones
- Post-op Fever
- Ruptured AAA
How often is SBO missed
SBO may be missed 30-70% of all
radiographs
• CT is preferred if available
Abdominal X ray reading approach
– Bones
– Stones or FBs
– Gas
• Extraluminal – free air/pneumatosis
• Intraluminal – dilation and air fluid levels
– Mass
• Look at all organs
Normal Abdominal series (xray)
Upright abdomen (pt must be upright for at least 5 min.).
Flat abdomen/KUB (aka supine abdomen)
PA CXR
more sensitive for pneumoperitoneum than upright ABD
(Might be just “Upright Ab” and “PA CXR”…unsure)
Abdominal X ray if unable to stand
AP Supine,
left lateral decubitus and
AP chest
(to be done if patient is unable to stand for upright abdomen or chest)
Free Peritoneal Air
aka
Pneumoperitoneum
• Free intraperitoneal air will accumulate under the right hemidiaphragm on an upright film.
(under the left is less common due to phrenicolic ligament)
Free Peritoneal Air
aka
Pneumoperitoneum
• Free intraperitoneal air will accumulate under the right hemidiaphragm on an upright film.
(under the left is less common due to phrenicolic ligament)
Usually seen with large amount of air (>1000ml)
Most vommon cause of Free Peritoneal Air
Pneumoperitoneum
A perforated viscus (intestinal perforation) is probably the most common cause of free air
Pneumoperitoneum differential diagnosis:
Perforated viscus (90%)
- Peptic ulcer
- Diverticulitis
- Appendicitis
- Toxic megacolon
- Intestinal infarct
- Neoplasm
What is Rigler sign
(double wall sign)
where gas outlines both sides of the bowel wall (intraluminal and extraluminal)
Seen on supine view (Pneumoperitoneum)
What does KUB mean
Kidneys, ureters, bladder
When to order KUB
Order this exam when you need a flat film of the abdomen only (e.g. large kidney stones, constipation, FBs)
(CT’s are more sensetive)
What combination of studies complete the abdominal series in a patient that cannot stand?
- PA Abd, KUB and PA Chest
- PA, Lateral and LLDP
- AP chest and abdomen, LLD
- PA, LLDP and AP Chest
- AP chest and abdomen, LLD
Bowel wall evaluation of malignancy
Tumor
Edema
Post inflammatory changes
Note an apple-core lesion, which is generally a sign of malignancy
CT Imaging of Abdomen
Preferred modality in majority of
Bowel abnormalities
Transverse is the primary plane
for CT evaluation
Transverse Plane
Viewed from below as looking
towards head
Sagittal Plane
• Looking at patient from the left
side
Frontal or Coronal Plane
• Looking at patient from the front
CT Windows
Important to distinguish
evaluation of specific tissue by
adjusting density
adjusting density
– Increasing the window level
decreases the brightness
– Decreasing the window level will
INCREASE the brightness of the
image
Appendicitis X ray
Most patients with acute
appendicitis have normal
abdominal plain films
• Do NOT use XRay to diagnose
appendicitis
Appendicitis in Peds
In a pediatric population
• RLQ Ultrasound is first-line
- CT with oral and IV contrast is the next step
- MRI if high suspicion but severe contrast allergy or pregnancy
Appendicitis in Adults
In an adult, CT with at least IV contrast is indicated
• Consider alternative studies if suspect other pathology or have low
BMI
• **Normal appendix is rarely visualized on an ultrasound
Abdominal/Pelvic Abscess imaging choice
CT
You are seeing a 13yo female with complaints of abdominal pain and
vomiting at a large academic pediatric hospital. Patient denies
diarrhea or UTI symptoms. She denies vaginal bleeding. Abdomen is
soft, patient has mild positive McBurney’s and negative Rovsing signs.
What imaging choice would be best to screen patient for suspected
diagnosis?
- Xray
- CT without contrast
- RLQ Ultrasound with Duplex
- MRI with contrast
- RLQ Ultrasound with Duplex
Bowel Obstruction, Free Fluid and Free Air
in Adults
DDX
- Adhesions
- Hernias
- Neoplasms
Bowel Obstruction, Free Fluid and Free Air
in Peds
DDX
- Intussusception
- Hernia
- Appendicitis
What are the normal calibers of small
bowel, large bowel/transverse colon,
and the cecum?
3=Small
6=Large
9=Cecum
You are seeing a 65yo WM wit Hx of multiple abdominal surgeries with 1 day worth of abdominal pain. Abdomen is tight, tympanic. Patient has had vomiting but no BM. KUB notes multiple small bowel dilated loops with air-fluid levels.
What is the most likely diagnosis?
- SBO
- Constipation
- Enteritis
- Appendicitis
- SBO
What does an ileus look like on imaging
enlargement of the GI tract
You are seeing a 9yo male with complaints of Abdominal pain. KUB shows distended large bowel at the distal transverse colon. What is upper limit of normal diameter size of colon in this region?
- 3cm
- 6cm
- 9cm
- 12cm
- 6cm
Crohn’s Disease
Ulcerations, erosions, and full-thickness bowel wall inflammation
• As with Ulcerative Colitis,
Crohn’s diagnosis can only be made via colonoscopy with biopsy.
Ulcerative Colitis
Superficial ulcerations, edema, and hyperemia of the colonic mucosa and submucosa
• Thumbprinting – indentation
Only in Large intestine
• As with Crohn’s
Ulcerative Colitis, diagnosis can only be made via colonoscopy with biopsy.
Sigmoid Volvulus
A closed loop obstruction of the bowel - twisting; can lead to ischemia and necrosis
- Most common in the sigmoid colon and cecum
- Usually seen in elderly debilitated patients with chronic obstruction.
Diagnosis is made by Barium enema or endoscopy
CT is preferred
Coffee Bean sign
Cecal Volvulus
- Displaced cecum (normal location is within the right iliac fossa)
- Small and large bowel obstruction up to the point of torsion
Barium enema does not extend to Cecal valve
• Less common than sigmoid volvulus
A coffee-bean sign can be observed in which
radiologic conditions?
- SBO
- Ulcerative Colitis
- Volvulus
- Intussusception
- Volvulus
Intussusception
Most patients are children less than 2 years old with a “telescoping” of the bowel
Usually idiopathic
Seen on plain film radiographs as a small bowel obstruction
• Diagnosis and treatment of pediatric intussusception is made by single contrast barium enema
Hirschsprung’s Disease
Congenital aganglionic megacolon
Meckel Diverticulum
Due to incomplete obliteration of omphalomesenteric duct causing fistula between ileum and umbilicus.
Clinically see painless rectal bleeding “currant jelly stools” in a patient <2yo.
Tc-99M nuclear scintigraphy is the study of choice
Toxic Megacolon
Extreme dilation of the colon in which the affected area of bowel loses all tone and contractility
- Ulcerative Colitis is the most common cause
- Rectum is usually spared
- Enemas are contraindicated due to high risk of perforation
Free Peritoneal Fluid
Large amounts of free air in the abdomen will appear more radiolucent (darker) than normal
Large amounts of free fluid in the abdomen will appear more radiopaque (whiter) than normal
Fluid = White Air = Dark
Flank stripe
Should be able to see the flank stripe on normal x ray with no fluid (ascites)
What kind of contrast do most abdominal CT’s require
at least IV contrast
Under BMI of 21 needs Oral contrast
Causes of bowel thickening
Crohns
Abnormalities like strictures, fistulas, shigella, abcess
Hernia
• Inguinal are most common (75%)
Diagnosis is usually clinical, but CT with IV contrast is the study of choice
Lower abdominal pain should always receive
genitalia exam to r/o hernia or ovarian/scrotal problems
Diverticulosis
herniation of portions of the mucosal and submucosal layers of the colonic wall
Usually painless but can lead to bleeding
Can become diverticulitits
Bladder fistula
Air inside of bladder
Bowel Neoplasms
Colorectal Adenocarcinoma
Applecore Lesions appearance
Appendicitis Imaging
Start with ultrasound
CT shows best
Vascular imaging of the bowel
for rectal bleeding
Bowel ischemia
Pain disproportionate to exam finding
• Mesenteric CT Angiogram is imaging of choice
AAA occur where
Most occur infra-renal
L2
3 types
Pseudomyxoma Peritonei
“Jelly Belly”
The morbidity and mortality from
this process is very high.
Presence of pneumatosis and pneumobilia on CT in a patient with rectal bleeding and abdominal pain usually represents what condition?
- SBO
- Bowel Ischemia
- Diverticulitis
- Ulcerative Colitis
- Bowel Ischemia
When do you get benign liver tumors
Benign tumors such as hepatic adenoma and focal nodular hyperplasia are more common in young and middleaged women who have been taking birth control pills or hormonal replacement therapy
When do you get liver carcinoma
Hepatocellular carcinoma, or hepatoma is more common in cirrhotic patients
What is the most common benign liver tumor
The most common benign liver tumor is the cavernous
hemangioma
Hepatic cyst imaging
With ultrasound, a hepatic cyst appears as a sharply defined round mass with a thin wall that is echolucent
Diagnosis of a liver abscess is confirmed how
by percutaneous aspiration, performed by a radiologist, using CT or ultrasound guidance
Best imaging for liver trauma
CT with oral and IV contrast is the imaging method of choice for liver trauma,
Unstable patient abdomen (liver trauma)
Fast exam first
Penetrating trauma vs blunt trauma
Spleen = Blunt Liver = penetrating
Biliary Tree imaging
Ultrasound first
Then
Ultrasound
Cholescintigraphy
CT
Percutaneous transhepatic cholangiography (PTC)
Endoscopic retrograde cholangiopancreatography (ERCP)
MRCP
Gall stone choleithiasis imaging
Ultrasound
95% detection rate
They appear echogenic
(shadow)
Cholescintigraphy
Nuclear medicine imaging of the
liver and gallbladder
HIDA Scan
20-30 minutes for uptake
24 hours to clear nuclear agent
Percutaneous Transhepatic Cholangiography
Carried out by injection of a water-soluble contrast material directly into the liver through the skin
MRCP
vs
ERCP
ERCP is invasive with a scope
MRCP is noninvasive
Common side effect fo ERCP
Pancreatitis
You are seeing a 35yo WF with chronic Hx of obesity for evaluation of RUQ abdominal pain following Church’s Chicken meal. She has a positive Murphy sign. What imaging modality would you order?
- MRCP
- Ultrasound
- Cholescintigraphy
- CT without contrast
- Ultrasound
Pancreas imaging
CT is the imaging method of choice for patients suspected of having pancreatic cancer, pancreatitis, pancreatic abscesses, and pancreatic trauma
Painless jaundice think?
Pancreatic mass
obstruction of biliary tree
Courvoisier’s law
the gallbladder is smaller than usual if a gallstone
blocks the common bile duct but is dilated,
if the common bile duct is blocked by something
other than a gallstone, such as pancreatic cancer.
Cirrhosis
Cirrhosis resulting from chronic alcoholismwill alter the size, shape, contours, or density of the liver
CT is the imaging method of choice for cirrhosis,
Causes of spleenomegaly
malignancy (lymphoma), hemochromatosis, thallassemia and many other conditions
Trauma and contrast?
All trauma below neck gets Contrast
Spleen trauma imaging
CT is the imaging method of
choice for splenic trauma,
with contrast
You are seeing a 55 yo WM who was involved in a MVC. He has
strong odor of ETOH. There is no external trauma besides a few
abrasions. Upon arrival his BP is 88/46 and HR is 122. What organ
is the most likely injured in this case?
- Pancreas
- Liver
- Spleen
- Small Bowel
- Spleen
• Pt is a middle-aged man who noted increased prominence in his abdomen after recovering
from a laparotomy a year earlier
Condition?
Incisional hernia
Middle aged male with chronic
alcoholism now complaining of
progressive right abdominal pain.
Condition
Large spleen and liver
Young male suffered multiple
trauma in a motor vehicle
accident. He is hypotensive.
Condition
Liver laceration
Spleenic rupture
40yo male in ED with Hx of right flank pain radiating to scrotum for 1 day and hematuria. Pain came on gradually and is 10/10. Naturally, you suspect kidney stone. Patient reports Hx of exploratory laparotomy following splenic rupture from MVC. Patient reports subjective fever and has RLQ abdominal tenderness on exam. Abdomen is soft. Patient refuses genitalia exam.
• Blood work and UA does not show anything exciting. His BMI is 20. What 2 imaging studies will cover all bases and exclude all most likely pathology in this patient?
Ultrasound of scrotum and testes with duplex
CT abdomen and pelvic CT with IV and PO contrast
