Radiology Flashcards
Xray feature of duodenal obstruction?
C-shaped dilated bowel >3cm
Xray feature of jejunal and ileal obstruction? (4)
• Dilated >3cm
• Central gas filled bowel
• stack of coins appearance: plicae circularis/ valvulae conniventes more prominent and pass completely across width of bowel, regularly spaced
• no gas in colon
Xray feature of colon obstruction? (3)
• Dilatation caecum > 9 cm or colon >6 cm
• peripherally located
• incomplete bands (haustrations due to Taenia coli) spaced irregularly, doesn’t cross whole diameter
Xray feature of sigmoid volvulus ?
Coffee bean sign: massive colon distention with dilated loop of bowel running diagonal across abdomen from right to left
Radiographic feature of caecal volvulus ? (3)
• Gas filled ileum with or without distended caecum - No longer in rif
• “fetal” appearance
• barium enema shows bird beak deformity
Radiographic feature of intussusception ?
Ileocolic: evidence of small/large bowel obstruction with absent caecal gas shadow (barium enema = claw sign)
Caecal: coiled spring sign
Xray feature inflammatory bowel disease ? (3)
• Thumbprinting: mucosal thickening of haustra due to inflammed oedema. Appear like thumbprints projecting into lumen = ischaemic bowel
• lead-pipe featureless colon: loss normal haustra markings (esp uc )
• Toxic megacolon : bowel wall oedema with thumbprinting, and pseudopolyps or “mucosal islands”
Xray features gallstone ileus? (2)
•Pneumobilia (cholecystoduodenal fistula)
• opacity near ileocecal value
Xray features pneumoperitoneum?
Rigler’s double wall sign - obvious “thick” bowel wall due to extra-luminal air
Ultrasound feature cholelithiasis?
Acoustic shadowing
Identify pathology picture 1
Coiled spring sign: intussusception or other causes small bowel obstruction
Nome the apparatus in picture 2
Sengstaken Blakemore tube used to control variceal bleed after self expanding metal stent or rubber band ligation has failed
Identify pathology picture 3
Stack of coins (prominent valvulae conniventes) and string of pearls (rows gas bubbles trapped between valvulae conniventes) sign: small bowel obstruction
Identify pathology picture 4
Stack of coins (prominent valvulae conniventes) sign: small bowel obstruction
Identify pathology picture 5
Coffee bean sign: sigmoid volvulus
Name 5 differences on xray between sigmoid and Cecal volvulus
See picture 6
Identify pathology picture 7
Coffee bean sign: sigmoid volvulus
Identify pathology picture 8
Fetal appearance distended large bowel from right lower to left upper: Cecal volvulus
Proximal dilated small bowel.
CT features of acute interstitial oedematous pancreatitis?
• Homogenous enhancement of pancreas
• peri-paneneatic fat stranding
• peri-pancreatic fluid may be present
CT features of acute necrotising pancreatitis?
Early CT scan may underestimate degree of necrosis: difficult to Differentiate oedema and necrosis
After first week any non-enhancing area of pancreatic parenchyma can be considered to be parenchyma necrosis
CT features pancreatic pseudocyst? (5)
• Well-defined wall
• fluid collection in peri-pancreatic tissue high in amylase
• contains no solid material
• can only be diagnosed 4 weeks after acute pancreatitis, takes time for wall to form (more common in chronic than acute pancreatitis)
• disruption of main pancreatic duct or intra-hepatic branch can lead to leakage of pancreatic fluid with persistent localised fluid collection
CT features of acute necrotic collection in acute pancreatitis? (3)
• Nonenhancing regions of pancreas
• collection containing variable amounts of fluid and necrotic tissue that can involve pancreatic parenchyma or peri-pancreatic. May be multiple, may appear located
• difficult to distinguish from acute fluid collection in first week. If after first week any non-enhancing areas, assume to be necrosis
Diagnosis walled off necrosis as a late local complication of acute pancreatitis on imaging? (3)
• on CT Encapsulated mature Necrotic tissue contained within well-defined enhancing wall of reactive inflammatory tissue
• May be infected, multiple and present at sites distant from pancreas
• CT may not readily distinguish solid from liquid content and may misdiagnose walled off necrosis as pseudocyst. MRI, transabdominal or endoscopic ultrasound may be needed to distinguish
What does double duct sign on ultrasound or CT indicate?
Both CBD and pancreatic duct are dilated
Head of Pancreas or periampullary cancer until proven otherwise
Identify pathology picture 9
Cecal volvulus: fetal shape
Identify pathology picture 10
Bird beak deformity cut off barium: cecal volvulus (solid arrow)
Dilated cecum lies in epigastrium where there is an air fluid level (open arrow)
Identify pathology picture 11
Bird beak appearance: cecal volvulus
Identify pathology picture 12
Bird beak deformity: Cecal volvulus
Identify pathology picture 13
Absence of air intestines and soft tissue density right: intussusception
Identify pathology picture 14
Claw sign barium study: intussusception.
Identify pathology picture 15
Thumbprinting = large bowel wall haustra thickening
Usually caused by oedema related to inflammatory bowel disease
Identify pathology picture 16
Lead pipe colon sign: classic sign in chronic ulcerative colitis
(Muscularis mucosa hypertrophy)
Identify pathology picture 17
Lead pipe colon: ulcerative colitis
Identify pathology picture 18
Barium study: total colitis and pseudopolyposis
= inflammatory bowel disease( ulcerative colitis)
Label picture 19 and give diagnosis
Toxic megacolon
Left = megacolon
Right - mucosal islands
Identify pathology picture 20
Gallstone ileus - rigler triad:
• small bowel obstruction
• gas in biliary tree
• gallstone in rif
Identify pathology picture 21
Gallstone ileus - rigler triad:
• small bowel obstruction
• gas in biliary tree
• gallstone in rif
Identify whether picture 22 is small or large bowel and why
Large bowel: haustra (black arrow) and plicae semilunaris (white)
Identify whether picture 23 is small or large bowel and why
Small; valvular conneventies
Identify pathology picture 24
Small bowel obstruction
Identify pathology picture 25
Large bowel obstruction
Identify pathology picture 26
Toxic megacolon in patient with ulcerative colitis (lead pipe colon)
Mucosal islands
Identify pathology picture 27
Rigler’s sign = double wall sign.
Indicate preumoperitoneum
Name 5 criteria for a normal cholangiopancreatogram
• Normal intrahepatic ducts
• no filling defects
• smooth CBD
• no stricture or narrowing of CBD
• good and free flow of contrast into duodenum
Investigations for cholelithiasis? (4)
• Ultrasound is best. More sensitive than Ct scan. Strong echogenic rim around stone with posterior acoustic shadowing. Bile should appear as black patch in gallbladder, if not homogenous = sludge
• mrcp: next step if need to work up further
• ercp:therapeutic
• PTC (percutaneous transhepatic cholangiography) or PTBD (biliary drainage): therapeutic
• CT: not sensitive for stones, do to assess complications
• AXR: most stones radiolucent so not great
• HIDA scan: not used commonly except in biliary atresia.
Name 3 therapeutic procedures that can be done with ercp
• Stone removal (using fogarty balloon catheter or Dormia wire basket)
• sphincherotomy (to relieve obstruction or facilitate removal stone )
• stenting
Name 4 complications ercp
• Acute pancreatitis
• infection
•Haemorrhage
• perforation
Indications percutaneous transhepatic cholangiography PTC? (2)
• Diagnostic: high biliary obstruction not well visualised in ercp or previous surgery with altered anatomy eg gastrectomy
• therapeutic: obstructed system that cannot be drained from below
Identify pathology picture 28
Mucosal thickening on left
Thumbprinting on right
= inflammatory bowel disease
Identify apparatus picture 29
Nasogastric tube for neonate.
Identify pathology picture 30
Distended fluid filled stomach, duodenum and small bowel seen on prenatal ultrasound
= congenital bowel obstruction
Left: dilated bowel
Right: small bowel atresia
Identify pathology picture 31
Xr of neonate:
High bowel obstruction- 2 air fluid levels (stomach and duodenum) with no air in rectum.
= duodenal atresia
Identify pathology picture 32
High bowel obstruction in neonate
Identify pathology picture 33
Hirschprung’s disease: massively dilated bowel loops filled with air.
Lateral shoot through = air fluid levels
Low bowel obstruction
Identify pathology picture 34
High bowel obstruction (ileal atresia)
Identify pathology picture 44
Incomplete obstruction. Corkscrew sign= malrotation.
Identify pathology picture 46
Left no air in rectum
Right target sign ultrasound
= paediatric intussusception
Identify pathology picture 47
Technetium 99m scan: Meckel’s diverticulum
Describe breast cancer appearance on ultrasound (6)
• Hypoechoic (dark gray)
• irregular shape
• margin not circumscribed. Angular, indistinct, microlobulated, spiculated
• vertical orientation (taller than wide)
• Frequently posterior shadowing
• may have small calcifications in or outside mass
Identify pathology picture 50 - breast ultrasound
Breast cysts = anechoic oval with circumscribed margin, posterior enhancement, horizontal orientation
Identify pathology picture 51 - breast ultrasound
Fibroadenoma
• Hypo echoic
• oval or round shape
• circumscribed margin
• horizontal orientation/wider than tall
• sometimes minimal posterior enhancements
• may have gross calcifications
Bottom picture has breast prostheses under muscle
Identify pathology picture 52 - breast ultrasound
Breast cancer
• Hypoechoic (dark gray)
• irregular shape
• margin not circumscribed. Angular, indistinct, microlobulated, spiculated
• vertical orientation (taller than wide)
• Frequently posterior shadowing
• may have small calcifications in or outside mass
Name 5 features esophageal cancer on barium swallow
• Irregular apple core stricture
• shouldering
• prox dilatation esophagus
• axis deviation or angulation
• TOF if present (tracheo-esophageal fistula)
Identify pathology picture 53 breast ultrasound
Breast cancer
• hypoechoic mass with irregular shape
• uncircumscribed border which is angular and indistinct
• small hyperechoic dots (califications)
• no posterior shadowing or enhancement
Identify pathology picture 54
Breast cancer on in mammogram: stellate irregular with calcifications
Identify pathology picture 55 breast ultrasound
Breast cancer.
• hyperechoic halo surrounding irregular hypoechoic mass
• vertical orientation
• irregular circumference
Identify pathology picture 56 breast ultrasound
Fibroadenoma
• oval shape (slight lobulation)
• sharply demarcated
• horizontal orientation
• posterior enhancement
Identify pathology picture 57 breast Ultrasound
Lipoma or fat necrosis.
• ISO or hyperechoic compared to surrounding fat
Identify pathology picture 58
Invasive ductal carcinoma (most common). Birads 5.
• hyperdense mass
• irregular shape
• speculated margin
• focal skin retraction
Name 4 mammogram findings of breast cancer
• hyperdense mass
• irregular shape
• spiculated , microlobulated or indistinct margin
• architectural distortion
• may have focal skin retraction
Identify pathology picture 59
Probable Breast cancer: architectural distortion
Identify pathology picture 60
Axial contrast CT in arterial phase showing abdominal aortic aneurysm
Name the 5 phases of a contrast CT scan
• Early arterial phase: 15-20 seconds after injection. Only in arteries
•* late arterial or arterial phase: 20-40 seconds. Optimal enhancement of organs with arterial blood supply
• * portovenous or hepatic phase: 80 seconds. Liver enhances
• nephrogenic phase: 100 seconds. All renal parenchyma enhance. Will only detect small RCC here
• * delayed or washout phase: 6-10 minutes. In fibrotic tissue
Advantages in detection of non-contrast CT scan? (3)
• Calcifications eg stones, chronic pancreatitis
• fat in liver tumours, adrenal adenoma or myelolipoma
• fat stranding steen in inflammation eg appendicitis, diverticulitis, omental infarct etc
What is normal flow on duplex ultrasound?
Triphasic
What does monophASIC flow on duplex ultrasound indicate?
Proximal occlusion
What does biphasic flow on duplex ultrasound indicate?
Proximal stenosis
Detection Benefit of early arterial phase of CT scan? (2)
• Aortic dissection
• arterial bleeding
Detection Benefit of arterial phase of CT scan? (3)
• Liver: HCC, FNH, adenoma
• pancreas: adenocarcinoma, insulinoma
• bowel ischaemia
Advantages in detection of porto-venous phase CT scan?
Hypovascular liver lesions eg cysts, abscesses, most metastases
Advantages in detection of nephrogenic phase CT scan?
Renal cell Carcinoma
Advantages in detection of delayed phase CT scan? (3)
• Liver cholangiocarcinoma
• Liver fibrotic metastasis, usually due to breast cancer
• Kidney transitional cell carcinoma
What is enhanced in delayed phase CT scan? (2)
• Fibrotic lesions
• kidneys ( not including medulla) and urinary collecting system
Nothing in blood vessels
What is enhanced in portovenous phase CT scan? (2)
Hepatic parenchyma
Portal vein is bright
Spleen appears homogenous
What is enhanced in arterial phase CT scan? (7)
• Aorta is bright
• spleen enhanced appearing heterogeneous
• hypervascular lesions
• stomach
• bowel
• pancreas parenchyma
• kidney outer cortex
Malignant vs benign ulcers on gastrosopy? (4)
• Large > 1 cm vs smaller
• irregular borders vs regular
• elevated border vs flat
•Base discoloration vs clean
Identify pathology picture 61
Fecolith in appendicitis
Identify pathology picture 62
Gastroschisis or omphalocaele with ruptured membrane with spring loaded silo bag covering
Identify pathology picture 63
Cobblestoning on colonoscopy from Chron’s disease
Identify pathology picture 64
Deep ulcerations on colonoscopy from ulcerative colitis
Identify pathology picture 65
String sign - terminal ileum narrowed, eventually wall fibrosis and thickening keeping it like that
= Chron’s disease.
