PCE chest and abdomen Flashcards
Identify the structures of the heart
Right atrium
Right ventricle
Left atrium
Left ventricle
Where should the left hilar sit in relation to the right one?
Left hilar should sit higher than the right hilar because it goes over the pulmonary artery
If it is lower this indicates heart failure or something else wrong
where is the carina?
The carina is where the trachea bifurcates it sits just below the aortic knuckle usually
How many lobes is there in the lungs?
3 for the right
2 for the left
Anatomy levels going down in left lung
Great vessels/ left paratracheal stripe
Arch of aorta
Main pulmonary artery
Auricle of left atrium
Left ventricle
Fat pad
Anatomy levels going down in right lung
Great vessels/ right paratracheal stripe
Superior vena cava
Arch of azygous vein
Superior vena cava
Right atrium
Inferior vena cava
How is the lung split up
Apex
Upper zone
Mid zone
Lower zone
Felson search pattern
ATMLL (Are There Many Lung Lesions)
Abdomen
Thoracic Cage
Mediastinum
Lung (unilateral)
Lung (bilateral)
Types of opacity
Consolidation- air spaced opacity, patching shadowing, can be quite dense
Interstitial- smaller fine lines, crossing over lines (can also reduce lung volume)
Nodule- small node usually a simple circle
Mass- large, may not be a simple circle
Atelectasis- lung collapse
Lymph nodes can get enlarged and can distort the hilum so infection is important to note
Lymph nodes can get enlarged and can distort the hilum so infection s important to note
What is a sail sign
lung collapse, dense line where the lung collapse
Slide 28, example of PCE for chest “Interstitial shadowing in the mid to lower zones
Slide 28, example of PCE for chest “Interstitial shadowing in the mid to lower zones
What causes lung collapse?
in older patients it can be due to malignancy
in younger patients in children and children it can be a result of mucus plugin if they’re asthmatic
Right middle lobe collapse appearance
Increased density and distortion of the hemidiaphragm (it should be a nice dome)
left upper lobe collapse appearance
Increased opacity of the left lung, called the veil sign as it looks like someone has draped something over the lung
The aortic may also be distorted because the left lower lobe has hyperinflated because the upper lobe collapse
pneumothorax how to describe
The lung doesn’t fill the chest,
Remember to say what side it is and whether there is a mediastinal shift
pleural effusion how to describe
say what side is affected or whether its unilateral
Loculated plural effusion is where it goes up the side of the lungs (periphery of the pleura, all the way up to the apex)
if horizonal fissure, is thickened with pleural effusion at the bottom, its also a pleural effusion
What is a empyema
basically a pleural effusion that is made form pus
it looks like a bulging opacity
Mesothelioma what does it look like
if you see an opacity that looks like a pleural effusion (empyema) but there is no blunting of the costophrenic angles its mesothelioma
How do you look for heart failure
Kerley lines (horizontal lines)
Increased heart size
Pleural fluid
Perihilar opacity
Upper lobe blood distribution
Using the silhouette sign
loss of the silhouette sign
Right paratracheal stripe: right upper lobe
Right heart border: right middle lobe or (medial right lower lobe - small percentage)
Right hemidiaphragm: right lower lobe
Aortic knuckle: left upper lobe
Left heart border: lingula segments of the left upper lobe
Left hemidiaphragm or descending aorta: left lower lobe
Mediastinal Masses
Anterior
Middle
Posterior
Anterior
The 5 T’s
middle
Lymphadenopathy
Central Lung Tumours
Oesophageal lesions
(Look for splaying of the carina)
Posterior
Spinal/Paraspinal Abscess
Neurogenic Tumours
(Look at the intervertebral discs and vertebral bodies carefully
Look for rib splaying)
Normal diameters of the bowel
Small bowel =
Large bowel =
Caecum =
Normal diameters of the bowel
Small bowel = 3 cms
Large bowel = 6 cm
Caecum = 9 cm
appearance of large bowel
Large bowel is peripheral and has haustral folds
appearance of small bowel
Small bowel is central and have valvulae conniventes
what are haustral folds
the normal folds of the large bowl, if they become smooth or have thumbprinting there is a pathology
what is Adynamic/Paralytic Ileus
symptoms
Radiographic Features
Paralysis of motility
Not due to mechanical obstruction
(usually link to post surgery)
Can be asymptomatic
Distended and tympanic abdomen
Tachypnea and tachycardia
No flatus
Hiccups
Generalised and uniform distension of small and large bowel
Can be sentinel loop if localised
What anatomy can be seen on a abdomen x-ray
liver
spleen
stomach
right kidney
left kidney
psoas muscle
ascending colon
transverse colon
descending colon
small intestines
rectum
bladder
(if there is issues with the gallbladder or the pancreas sometimes these can be visualize)
What can be assessed on abdomen?
Bowel gas pattern
Bowel wall
Abnormal gases
Masses
Calcifications
Foreign bodies
Bones
what are valvulae conniventes
the lines on the small bowl which go through the bowel whereas haustra is like a bumpy line
What causes bowel distention or enlarging?
Adynamic Ileus
Mechanical Obstruction
LBO
SBO
Volvulus
Small bowel obstruction
radiographic appearance and causes?
Small bowel distension (greater than 3cms)
Ladder-like or stacked coin appearance
Little to no air in the large bowel
Fluid-filled obstructions can be occult on plain film
Causes
Adhesions
Hernia
Gallstone Ileus
Intussusception
What is gallstone ileus
appearance?
Gallstone which has migrated from the gallstone through the bile duct and cause a perforation through that, so you can see that communication.
So what happens is you get gas in the billery tree that you wouldn’t expect to see.
So if you see gas in a billery tray, sat of that right of the quadrant.
And appearances of a small bowel obstruction, it’s probably due to a gallstone ileus, even if you cant see the gallstone
Large bowel obstruction appearance
causes
Dilated large bowel to the point of obstruction (transition)
Little or no air in the sigmoid/rectum
Little or no gas in the small bowel if the ileocaecal valve remains competent
Causes
Tumour
Volvulus (Sigmoid or Caecal)
Hernia (Rare)
Diverticulitis
Intussusception (Rare in adults)
Faecal impaction
Sigmoid Volvulus appearance
Arises in pelvis/LLQ
Extends towards RUQ
Ahaustral
‘Coffee-bean’ appearance
Dilated large bowel
Caecal Volvulus appearance
Arises in RLQ
Extends towards epigastric region/LUQ
Hausta maintained
Small bowel dilated
May have air fluid level
What is volvulus
Volvulus occurs when a loop of intestine twists around itself and the mesentery that supplies it, causing a bowel obstruction.
What is Pneumoperitoneum?
gas outside the bowel, sometimes under the diaphragm. Needs to be reported back to the ward
Perforation of the bowel
Iatrogenic
Rigler’s sign (air sign)
Visualisation of the Falciform ligament
What is intramural gas?
gas within the bowel wall, bacteria in the wall causing it.
Gas within solid organs
describe what you see,
could be in the kidney, bladder, liver, spleen etc
Assessing the Bowel Wall
Bowel wall thickening
secondary to submucosal oedema
neoplasm
Loss of the normal haustral pattern
‘Thumbprinting’ of the colon
Intra-abdominal Masses and Organ Enlargement
Causes mass effect (displacement of the surrounding tissue)
Urinary retention and bladder distension can mimic a mass
could happen to the bladder, or the liver
Calcifications types
Are a pathology or indicate a pathology
Concretions-Stones
Conduit-Fluid filled hollow tube
Cystic-Wall of structure
Solid mass-Extensive but variable
Calcifications examples
Renal and Ureteric Calculi
Gallstones
Porcelain Gallbladder
Vascular/cystic structures
Nephrocalcinosis
Lymph nodes
Phleboliths (in a vein)
Bladder calculi
Calcified aneurysms
Calcified splenic artery
dermoid cyst
Renal tract calculi
Left large renal calculi (stathorn calculus)
VUJ (Vesico-ureteric junction)
common foreign bodies, note slide
pessary ring, and that’s for prolapse
ueteric scent
hip replacement
common foreign bodies
pessary ring, and that’s for prolapse
ureteric scent
hip replacement
PCE note say what side is affected and say what quadrant the issue is in if cant say what the pathology is
PCE note say what side is affected and say what quadrant the issue is in if cant say what the pathology is
what is a dermoid cyst
usually in the midline and looks like teeth, germ cell tumour
How to describe foreign bodies
where is it, how many, what is it/shape
if there is clothing state it so that there is no confusion
What is ETT
Where should they be
What are they for
Endotracheal tube (ETT)
2cm above carina (ideally 5-7cm)
Wide bore plastic tube inserted into trachea to allow artificial ventilation
Adult tubes are usually around 1cm diameter
Radiopaque strip so they are visible on CXR
5-7cm above carina
Can move up and down depending on head/neck position
What is NGT
where should they be
What are they for
Nasogastric tube
3-4cm below diaphragm
Extend from the nose to stomach
Allow administration of artificial hydration and feeding, and deliver drugs
Patients who are unable to swallow
Patients who have sub-optimal oral intake despite intake swallow mechanism
Can be kept in place for 6-8 weeks
NG tube imaging criteria
Ideal PCE comment
(Request form should clearly state the purpose of the x-ray is to establish position of NG)
Does the tube follow the path of the oesophagus and avoid the contours of the bronchi?
Does the tube clearly bisect the carina or bronchi?
Does it cross the diaphragm in the midline?
Is the tip clearly visible below the left hemi-diaphragm?
“NG tube in situ, it bisects the carina and diaphragm in the midline. The tip is seen below the left hemi diaphragm overlying the gastric bubble”
Ideal NG PCE comment
“NG tube in situ, it bisects the carina and diaphragm in the midline. The tip is seen below the left hemi diaphragm overlying the gastric bubble”
Methods for confirming NG tube
Aspirate from tube and measure pH
Should be under 5.5
If no aspirate or pH is above 5.5 then an x-ray is justified
Types of NG tube and appearance on x-ray
Narrow bore, which has a guide wire through the length of it
Wide Bore which the tip may only be visible
Where does the carina sit
Level of T4 but on older patients it might become lower
What should you do if you see a NG tube is not in the stomach?
Call the ward and let them know not to use it and also document telling them. Ask for GMC, NMC, HCPC
If the tip of an NG tube is not visible what should you do?
do an upper abdominal view
The tube should go straight by the carina shouldnt bend before that point
PCE comment for an NG in the wrong place example
NG tube has gone down right bronchi and is sitting in the lower zone of the right lung
Comment on any pulmonary oedema etc also
any other artefacts, e.g ECG artefact, clothing
What happens if malposition of ETT?
Tube below the carina
Might go down right bronchus/only supply that one with air
left lung collapse due to no air
Right upper lobe collapse
Right lung over distension and cause pneumothorax
if in oesophagus
Stomach distended filled with air
Oesophagus will sit slightly lateral and not central as it should
What does Consolidation mean?
patchy/fluffy appearance, something is in the airway that shouldn’t be there.
ETT ideal location on x-ray
Endotracheal tube superimposes the trachea and sits above the carina around the level of T4
Intercostal chest drain what is it for and appearance
Chest drains are inserted for pneumothorax/pleural effusions.
Drains usually point superiorly if its for a pneumothorax and inferiorly if its for a pleural effusion (but not always).
check that the holes are in lung fields
intercostal chest drain PCE comment example
“intercostal chest drain in situ”
“There is also marked emphysema on right side” (if there is emphysema)
and the pathology
“right sided pneumothorax”
“Left side plural effusion”
CVP central venous pressure line
inserted via jugular vein (sometimes subclavian veins) and goes to the superior vena cava (SVC)
Usually inserted on the right
they measure/monitor atrial pressure and give meds
Should be straight tip
if gone too far into right atrium it can cause arrhythmias
CVP PCE comment example
“Central venous pressure line in situ in the superior vena cava”
Cardiac pacing device
what are they for?
Where should the wires sit?
Risk of anything?
Used to treat arrhythmias and bradycardia
2 leads usually
Ventricular lead points towards the apex of the heart (right ventricule)
Atrial lead usually points superiorly
Check for pneumothorax
Cardiac pacing device PCE comment example
“Cardiac pacing device in situ with wires in right ventricle and left atrium”
Comment on any pathology e.g pneumothorax
Cardiac defibrillators
what are they for?
What do they look like?
Monitoring and therapy
look similar to pacemaker but have a thicker lead
Cardiac defibrillator PCE comment example
“Cardiac defibrillator in situ with wires in right ventricle and left atrium”
could say cardiac device in situ also
Comment on any pathology e.g pneumothorax
CRT-P and CRT-D
Appearance
what is it used for
similar to cardiac pace maker in appearance but has 3 wires
Extra lead in the coronary sinus, around the left side of the heart. Used to treat patients with marked heart failure who are poorly managed on maximum medical therapy.
CRT-P and CRT-D PCE comment example
“Cardiac device in situ with wires in right ventricle and left ventricles and left atrium”
Mention any pathology
Valve replacement PCE comment example
“prosthetic heart valve in situ”
circle in the heart is the appearance
TAVI PCE comment example
and appearance
“TAVI in situ”
A cage like structure in the aorta
LVAD
Left ventricular assist devices (LVAD)
PCE comment example
only parts of LVAD are radio-opaque
its a big device that sits under the heart
“LVAD in situ”
Abdominal lactogenic object meaning
introduced by surgery
Gastric band appearance and PCE comment example
it has a band/circle to it and then a wire going out from it
“Gastric band in situ”
EVAR – Endovascular aortic repair and PCE comment example
“EVAR in situ”
This stent has ‘legs’ which go into the iliac arteries.
Gastrostomy tube and PCE comment example
“Gastrostomy tube in situ”
circles in abdomen not a large circle or band like the gastric band
Baclofen pump appearance
and PCE comment example
“Baclofen pump in situ”
Large device in abdomen region with wire going into the spinal cord
give meds
IVC Filter what is it
whats it for?
inferior vena cava filter
Used for patients at risk of PE where anticoagulants are contraindicated. Filters will be removed. The longer the filter is in, the higher chance of complications or failed retrieval.
IVC filter appearance and PCE comment example
“inferior vena cava filter in situ”
looks like a umbrella almost
Peritoneal dialysis catheter and PCE comment example
“peritoneal dialysis catheter in situ”
A thick tube like structure siting in the side of the abdomen with thinner tube across and down the abdomen
Encapsulating peritoneal sclerosis – constant ambulatory peritoneal dialysis
wont be in PCE
Encapsulating peritoneal sclerosis – constant ambulatory peritoneal dialysis
wont be in PCE
Vaginal pessary appearance and PCE comment example
“Pessary ring in situ”
A right in the bladder region quite large but not radiopaque
Nephrostomy appearance and PCE comment example
“left nephrostomy in situ”
A tube curling around in the kidney
Ureteric stent appearance and PCE comment example
“left ureteric stent in situ”
A tube from kidney running down uretera to bladder
state whether there is calcification around the stent also
Hernia mesh repair appearance and PCE comment example
Numerous small ‘spring-like’ artefacts overlying the lower right anterior abdominal wall.
These are from part of a mesh hernia repair of the abdominal wall
“mesh hernia repair in situ”
Capsule endoscopy appearance and PCE comment example
A radiopaque little tube almost square, can be anywhere within the bowel, and even by the rectum
“Capsule endoscopy in situ”
What does subpenic mean?
The subphrenic space is a peritoneal space between the anterior part of the liver and the diaphragm, separated into right and left by the falciform ligament, and postero-superiorly bounded by the coronary ligament.
Quadrants of the abdomen
Right upper quadrant
Epigastric Region
Left upper quadrant
Right lumbar region
Umbilical region
Left lumbar region
Right iliac region
Hypogastric region
Left iliac region
What is the appearance of ascites on an abdomen x-ray
Ascites is a build up of fluid due to liver failure.
It can lead to a swollen stomach and increase grey appearance (cant see bowel gas clearly) and unable to see the psoas muscles.
“psoas muscles shadows not visualized, there is an increased grey appearance and lack of bowel gas marking, in keeping with ascites”
What is pneumobilia
Pneumobilia, is when there is air in the biliary tree of the liver.
This leads to a branching gas appearance in the liver. Can be due to recent surgery.
“There is a branching lucency in the RUG, liver in keeping with pneumobilia” “Surgical clips in situ”
What is Chilaidaiti syndrome?
Where bowel is above the liver in a chest x-ray, may be normal for a patient if it is on previous imaging
what is a staghorn calculi?
A kidney stone that has taken the shape of the inside of the kidney
“there is a left staghorn calculi”
Small bowel obstruction comment
“there is a stacked coined appearance of distended bowel, in keeping with small bowel obstruction”
Normal appearance of calcification of the splenic artery looks like what?
Calcification of the splenic artery looks like a Chinese dragon (known as the Chinese dragon sign.) if there are converging plagues of calcification, this indicates an aneurysm of the splenic artery.
What is a phlebolith?
phlebolith - in veins round smooth opacities, may contain lucent centres, may confuse them with ureteric calculi
What are osteophytes?
Osteophytes are little bits of bone growth that come off from the bone and are linked to osteoarthritis, they are around joints, (where ligaments attach) and may appear on the spine also
What is rigler’s sign?
This is when you can make out both signs of the bowel, due to perforation, and the bowel has sharp edges to it.
