Abdominal X-Rays Made Easy 1st ed

Abdominal X-Rays

Made Easy James D. Begg

ae es FIlCll

Cc:nult.lntR.td ~, ~.. \ic1vN ~t.ll.

"""""

IIId Homr.ary Smior Lrctun'r in ~R.tdIl1logy.

l ni''f'r,jty Pl DJnd.." ,

Xu&rdt:K

A •

CHURCHill LIVINGSTONE En\BL'RCH I1X\TX JN MW,\,()l/.K J1 111.AIJHJ'-1IA snres 5YlY.\TI TORONlU I'HI

Contents

1. How 10look at an abdominal X-ray 2. Solid

orga ~

3;

3. Hollow organs 55

t Abnormal gas 86 5. Ascnes lI b II. Abnnnnal intra-abdo minal calcification

\HI

7. The fl;'mall' abdomen 154 8. Abl:h'minal lta uma

157

9. Ialmgt'nic objects 1M

10, Fi.lf\'ign bodjes, artl'fdcts. 11. The «ull' abdomm 12. Hinh

Indn

183

17\1

In

JJrisk>dJin~ illldg~

170

C a fer 1

How to look at an abdominal X-ray Ap roach to the film •

•

•

The init ial inspec tio n of an y X-ray be gin s w ith a technical assess ment. Establishment (If the name, . .1.111;', date of birth, agl.' and sexof the pollit'nt at the (lUtset is crucia l. There art' no prizes for making a brillia nt d iilgnos is in the wrong patien t' Further information relati ng to the wa rd number OT hospi tal of origin may give an idea as to the potent ialna tu re of the patient' s problem, e,g. gastroin tes tina l Of urinary, .111 (I( which information ma y be visible on the name badge, so never falltolock at it critically. Th is can be wry helpful inexams. You will notice, however. that the dalilon the patients' name badges

in this book haw had 10 be Il.'ffiUVOO to preserve their anonymity. Establish the projection of 1111' film, Virtually t'wry abdominal X-ray is an AP film, l.e. the beam p,l SSl'S from fro nt to back w ith the film behind the patient, who is lying dow n wit h the X-ray m achin e overhea d . but these are freq uently accompa nied by e rect or eve n dec ubi tus views (a lso APsl , Usually the radiographer will ma rk the film wit h a badge or wri te on it by h and 'Su pine or 'EI'l'Ct' to guide you, so seek this out and use it, Later on you must learn to work out for yourself how a given film wa s taken, from the relative pos ition s of organs, fluid, gas etc.

NOthe standard 35• .0 em cassett e used to X-ray an ad ult is tan talisingly smaller than theaVl'I'agl' normal human abdomen , and usu ally Iwo films all;' required to get the entire anatomy included from the dia ph ragm to the groin s, Make sure this has been don e before accept ing an y films for d iagnosis, If you don' t, you will miss something impor tant and you wo n't know you've done it! In obese patients casset tes may have to be used transversely, i.e. in 'landscape' as opposed to 'portrait' mode. Rotation is nol usua lly a probl em as most patients art' happy to lie on their backs. Underpe netration is not usually such a pr oblem as in the chest. If yo u can see the bones in the spine, then mos t of ever vthmg else you need 10 see will

Approach to the fil m continued probably be vislble as well. However; any overexposed (i.e. excessively dark)areas on an X-ray must be inspected. again with a bright light behind them (built into many viewing boxes for this purpose, or available as a separate device), as failure to do so may cause you to miss something very importa nt, such as fret' air under the diaphragm, representing a potentia lly fatal condi tion. It is worth knowing that only five basic densities a re normally present on x-reys, which 'lppear thus: Gas

Fot Soft tissue/fluid Bone/ calcification Metal

black dark grey light grey white intense while

so you can tell from its densi ty wha t something is made of. There is, however, a summa tion effect with large organs such as the liver which, because of their bulk, can approach a bony densit y. In the abdomen the primary structures outlined art' the solid organs, such as the liver, kidneys and spleen; the hollow organs (i.e. the gastrointestinal tract); and the bones. These structures can be classified as: L 2. 3. 4. 5. •

•

•

2

Visible or not visible, and there fore whether presen t or potentially absent; Too large or too small; Distorted or d isplaced; Abnormally calcified: Containing abnormal gas, fluid or discrete calculi. Take a systematic approach and work your way logically through each group of structures as a checklist. Initial inspection may reveal one or two major and obvious abnormalities, but you must still drill yours elf to look through the rest of the film - and you will frequently be sur prised. by what you find. Think logically.You should be able to Integrate your knowled ge of anatomy, radiogra phic densi ty and pathology with the findings on the X-ray,a nd work out what things are and what is going on. Look upon x-rays as an extension of physical examination, and rega rd radiological signs as the equiva lent of physical signs in clinical medicine.

The abd ominal X-ray: sca nning the fil m The supine AP film This is the film most frequentl y taken and shows mos t of the stru ctu res to the best advantage. The optimum information can only be obtained from it by using the correct view ing cond itions. An X-ray shou ld only ever be seriously inspected by uniform tran smitted light coming th rough it, i.e. a viewing box . There is no place for wa ving it about in the wind as irregula r illum inat ion a nd reflections will prevent 10-20% of the use ful information on it being visualized. Look for (Fig. 1.1):

• • • • • • • • • •

•

,

The bon es of the spine, pelvis, chest cagr.- (ribs) and the sacro-iliac joints The d ark margins ou tlining the liver, spleen. kidneys, bladder and PSOilS muscle s - th is is intra -abdominal f,1I Gas in the body of the stomach Gas in the d escend ing colon The wide pe lvis, ind icating that the pa tient is fema le Pelvic p hlebolith s - norm al finding Minor joint space narrowing in the hips (norm al for this agel The granu lar texture of the amorphous fluid faecal matter containing pockets of gas in the caecum, over lying the right iliac bone The 'R' marked low down on the right side. The marker can be anywhere on the film and you often have to search for it. All references to 'right' and 'left' refer to the 1\!/ifIlI'S righ t and left. Note the name badg e at the bottom, not the top. Check that the 'R' mark er is com patible with the visible anatomy, eg - liver on the righ t - left kidney higher than the right - stomach on the left - spleen on the left - heart on the left, when visible. The dark skinfold going right across the upper abdomen (nor mal).

The abd ominal X..,.ay: scanning the film Hepatic liver

Bexure

Skin fold

conl'nved

[, ; kidney

Splenic Ilell.ure

Gos in -descending <0100

_ Gos in body of stomach

[,; p>oo' margin

--~"l!!!:i:!- Sccro-ilcc joints

1I::=:i!~- ,,=* Bladder _ Phlebolith

, Fluid faeces and gas in caecum

Fig. 1.1 - Adult supine AP radiograph in a 55·year· oldwoman.

5

The abdom inal X-ray: scanning the film conlinved

Rugal folds and gas in sto mach

Shadow of peni s (indicating male childl and cndroid pelvis

llne of unfused fe moral epiphysis

Fig. 1.2 - SupineAPradiograph of a child with leN·sided abdominal poin.

6

The abdominal X-ray : scc nnin g the UklkJt( Fi~.

• •

hlm

conltn....,a

1,2):

The 'rijo;ht' m arker at thetop left-haod corner of the film The heart ~h.1JIIW tin tfu- !\dID!' ~iJI' abo ve the right hemi dla ph ragm tdcvrrocard ia)

• • •

Theoutline \If the stomach f;ols and ruga l lolds 1m Ilk' right TbeIin-TI'" the Loft Unlu~ tl'lphy....... in tht' femora . This is d child \\'hr"'t' gro..... th is mcomp lcte , his small ..i / l' 1,·.IJinjo; to tht' inclusion tlf 1,"-, Ill.... W r hest and UPf'l'f th i ~hs o!s well a~ all oi tho.- d~"n"..n - norrt'"ot'ntinio\a f"lrti.tl ·b.tbn~ra m' ",. il i" kno..... n

in raJK1K'KY'

\8 This \\;a.. rh't a T.lJi',;r,lrhic error ~l d ~t'n uint' "ilu.. inversus with 1.1t..;;'f..J ~lCitl._

As....ilh Itk- c~l or a limb, t-.t.lbli'ohmt'llt at left and right is t"""ol'!\haL You do noc want ttl remove a fKll1J\dl "kim'y from rbe right side when it is the l~'(ln tht'

Irtl tlw t b.JI"lW....-d, MdU....•til a fdUlly X-ray (and thi!'o ha.. moo dollt.'!). Both in and in clinical practin' ~ilu" inver..us, or mirror Iran!'oP'o",ilion of the ibdomin.al contents. may tlfl1r be diJ~Tl(""",l'ol e m>m 1M apparmt iocompatitoihly oflhr L/R mar\.t1' and lht-' ; ..rble,u\,llt.my wben it has been owrb>lt'IJ chnKally. Tbe L/R mJrh,. I1\dY of (IlUN' be looJl1\'ctlyplaced ibdf as a result I,f radioj!;faphk error, and thi..haPP'o'Th \~rith di...u rt>in~ fm.IlWnt:'Y (t"Speridlly with limp.. in aswll~'l _ You mU'>lIht.'Tl ~(l bad. and clk'Ck \\ith tnto radiographt.-r fiN MtlT\' ml!odiagnt.... m~ -uu.. mversu-, tll" unmu......,lrily n-qUt...ting a further X- ray• .\!'o.\ taull\· film ran 1-1' (w n,·lt, l wtth a pen. If in JuuM . n-evarnirwlbe p.ltit'TIt. f"Um~

\I oroll: Alwol y' ( heck Irfl and right on r ,"rl)" film. ~urgiu l o~u l ion ...

(on<,(iou~I)·

and rout inely -

t!oPfiully ju..t be fore

7

The abdominal X-roy: scan ning the film conli" .-1 look a t the bo ne s These pr ovide a u....-ful ~l.lrl inf; fII linl with whic h r nos t students MI.' fdmili.n. and

J Tt' Tt'ldli\'t'ly constan t in appt."lTilnre. The lower most ribs.fu mbar spine , sacru m. pt.'I\'i~ and h i ~ .HI.' all usuallv vi..ible to a ~11'i1 l!;'T UT It""t'l deg ree. The ~hdf't' of the pt'h'i~ will inJ ira l!;' the ....-x of the pa tient . The bo nes may also chow evidence (If ",'('onJa TyTTlilIif;lldnt disease, corticalthinning may reflect oste0p'lTI)O;j~, and degenerative (ha n~t's will increase wi th the agt' (If the patient. Overlying gas can be ,1 problem in the abdomen, l>bscuring genuine bomlesion... and !':1'Ot'Tatinf; fa l~' on e, (especially O\"l;'T the sacrum). The di~o\"l'TY of Pagt'l'S Ji"l'd'.I.', myeloma or meta ...tatic di;,('il~', however; willotten TTIiIh' YOUT search worthwhile. Lt_,k at Wig. 1.3): •

The bones: the inilidl routine in..penon of the hone; showed an incidental finJin g ( If l.'\ tt'TI-.iw ~11.'Tl.l';i ... in the right side oi the pelvis compared with the other norma l sidt', and some slight bony expanston.

This is Pagt'!:' s disease, a pl'\'TTlilliglldnl condition in 1% of patients. ~f or;l l :

8

Alw;lys chec k th e bon es .

The abdominal X-ray: sca nning the fi lm c:oMn.-J

Fig. 1.3 - Unilolerol5C/erosis - right ltemjpelvis This is a 62·year-old mole potient X-rayed for unexplained abodominal pain. No radiological coose was Found onthe plain film ~ but endo~copy showed a duodenal ulcer.

9

The abd ominal X-ray: sca nning the film con lin.....d

Fig, 1.4 This is a 2().minvle IVU Film from a 68-year-old man with a craggy moss palpable anteriorly on PRand haematvrja.

10

The abdominal X-roy: sccnmng the film «Jfl~"..,.d 1.IIIIk dl (Fi);. IA ):

•

The bonec tht.· f\' ,In' multiph- dense flri in the f'l'lvi!> a nd vertebrae of Iht'

lumb.u ~f'tnl·. ~'dft>

typil'dl "dl'rllti~' lTk1d... t.I"l~ frum d carcinoma of the prostate.

\toral: Always chec k the bon e...

lotll<. .II IFi);. IS) : •

Thl' cxn-n ...ive dark m.,"'ri,ll ... u n"un di n~ a nd ~t.u l<.l y cllnl r,}~l in); with th e jo;ut ilOO t"'f'l'idlly tht.·lo.iJllt·Y" , P"'"Jd,; muscles, live r i1nJ spleen .

Thl" 1'> the intrdf'l"liltlnt'al and retropernoneal fdl and it is thr~ that f\' ndt'r.> tbe Wnry,; and p-otJd" mu-cle, vrsrblc on convenuonat X-ray Irlms. Conversely, ~I til thi.. tolt bv, fur t'umrl e, h.wrntJTTha};t' or lumOUT. will obscure t~ll\iIrgin...

\8 The muTt' fal th.lt i-, pn.....-nt, the furtht'T thl'

liJ~'" trnJ

to be located

a....-. ~· from I"" ~pine. Thi .....huuM 0111 be rm..illl~'fJ'Tl'tt"l1 i1" p.lthological Ji!>pLKt--

""'"

-======; ; ; ; ; ; ; ; _

T ip of liver wal Abdominal muscles - Gut

· Block Innccbdomnc l fat

_ Tip 01 spleen

_. Kidney · Psoas muscle · Exleflsor muscles of spil'le · lumbar vertebra Fig. 1.5 Intra-obeJomil'lOl fa, This jJ 0 normal abdominal CTscan at !he levelof the kidneyJ. II

The solid

ns lviK e ral

look for the psoas muscles [Fig.l. l) These form two of the few straight lint'S seen in the body. They form diverging and expanding interface, exlt'nding infeftll.llt'rally from the lumbar ~pine 10insert on the 1t'S'ol'r tnxharucrs of the femora . and are very important retropentoneal landmarks. Thei r non-vtsuahzation may reflectserious di~',ISt', but there
took for the kidneys (Fig. 1. 1) These are u~udlly seen as bean-shaped objects of soft-t issue dmsity high in tht' ul'pt'r part of the abdomen. They art' usually smooth in outline, e\t.'nding from the upper border of T12 on the left stdc to the lower border of L3 on the right side, with the 1.,1\ kidnt>y Iring slightly higher than tfu- righl J.nd about 1.5 em biAA.'r. Both kidntoys incline slightly rnt'tli.llly about 12" towards the spin.. oil their upper poles. Normally they .ire wry mobile, m(l\'in~ dow n wi th inspiration, dfl>ppin~ several centimetres in the erect position. A consctou-, effort must dlw,]ys be made Itl find them, U~ud ll y, however, only pariS of their outlines anvisible and you rnJy have to Illok \'l'1"Y ha rd to try and deduce exactly where they lit, and how big they actually are. Ot:ra~hHl
,111<1

look fo r the liver (Fig. 1. 1)

Theliver, ht'ing.l solid org,m in the right uppt'r quadrant, presents as J large area uf son-tissue den~ity, its bu lk usually preventing
12

Ih e solid orgo ns

COI'IIrn"";/

ob-arccttve r Ulmtln,l ry d i....·,N· m.lYr ush tht' d iaphragm and liver down, crt'.lSdllung m.-. rki ngs an' etten visible through Ih.' liwr.

Look for !he spleen (Fig. 1.11 This form.. a ....Ifl liSSUt' m.lss in Iht' It'll 1lrJ'l'f quadrant about the ..ize of th.'

patient's fl...1 or heart. It m.lY hl.' ...."" w t'll or pdrtiJlly tlb<.L-un'd, bUI in fact i.. ottt.'O nol -ecn .It 0111. COlbidt'f.lbll' l;'T\1.:l~l'Ill'llt i.. Ol'(l"o... l~· IIIdl'll'd: it clinically kJl: . up to Ihrt'\' uroe, nurmall, allhotlJl:h .. mal1t'1" d~n_ til enlargement II1.iI~' hi' ..hown on a radiograrh Undl'!" favourableconditions . 5r1l'flic l'Ill.lrg.'m ent greater than 15 rrn will tend to dLspl.Kt' .Id~ltvnt slrut1un"> and has m.m~' GIU.,..."

led:. for the

b~o(Jder IFis,

1. II

\\lthin thl' pelvi.. .I I,Hgt' mass (If ....Iit-tb..ue dl'll ..ily ( fad i~a rh ica ll y water Jt'lbii)o' '" .... >tt·h ....ue dl'll-..lh' . mJy be rn....'tlI.lS a ~ult IIIa full bldddt'f outlint.>d

by pt'ri\ 'e-ical jolt, dod in

jl'ffidll~,

evee nunnally, volume. up to two tnres may

cccur. pushing 0111 tilt.' gut up oIM 'JUt of till' tru e pelvi... If there is d'lObi as 10 the natun" of ..uch a ma....a p'''I ,micturilillO film may ht· taken Of an ultra amd -can

J,:w. Bt-ing fullt" fluid, tlw tolokidt'1" behave.... r.wioJl:fdphKdlly Iik a llid ~n.

led:. for the

ute rus

Thb fadit~faphicall~' .... llid vructure ..ib 110 hiP of and ma~' indent tho: tolokidt.... II lNyoa:a..itlnall~' be ....'t'n ..pt.lnldnt'tlUsl~' dod i.. often well demon..trated indil\'ctl~' al an IVU t'\Jmin,ltiun, (,lll"lng ,1 di ..unrt concavity on the uppt.'r t>dge of Ihl' bladdt'J, In m,m~' patient.., hllwt'wr, il cannot be id..nnned on pla in film...

13

The hollowviseere (gas-containing gastrointestinal troctl

On a normal film, any structure outlined by g,lSin the abdomen willbe part of the ~astmintt'stin,ll tract. Remember: on a supine AI' radiograph the pauent is lying on his back, so under gravity ilny fluid will lie posteriorly within the gut and the g,b in the bowel will float anteriorly on top of it. NB fluid level s do nol appea r on su pine AP fil ms,

Failure to appreciate this mdY lead to ~mss misunderstanding and l'Hors in diagnosis. To demonstrate fluid levels you need an /'reel film or a dl'ClJhilw; film taken with a horizontal beam, Think systematkally and work your way down through the gastrointestinal tract. identifying structures (rom the stomach to the

rectum. look for the stomac h ln the supine position, depending ()11 how much is present, the g,lS in the stomach will rise anteriorly 10 outline variable volumes of the body and antrum of this structure. to the left of and across the spine around the lowermost thoracic or upper lumbar levels. Simultaneously the resting g<1strk fluid will form ,1 pool in the fundus beneath the didphragm, posteriorly on the left-ha nd side, crt\lting a circular uuthne - the 'gastrk pseudotumour - which should not Do.' mistaken for an abnormal renal. adrenal or splenic m,I.SS, althuugh occasionally it is and requests aft' received in X-ray to 'invl'Stigatt' the ldt upJX'r quadrant mass'. Try to avoid this mistake. The mass can be made to disappear by turning thl' patient prone or silting him upright, when the familiar fund ,11 g,IS bubble, commonly bestseen on chest x-rays, will Jppe,lf with a fluid leveldirectly beneath the medial aspect of the left hemidiaphragm (erect film). Look at (Fig. l.h): • •

The gas lying anteriorlv in the body of the stomach The fluid pool f'll':>!<,riorly - fhe g.lstric pseudotumour.

The hollow viscera ton"nuttd Gastric psevdotumour in

fundusof stomach

Gas in ~nt pori

01 duodenum

Gas in body of stomoch

Fig 1.6 - This ;$ rile wpine radiograph 01 on odvh, ovrIin;rtg /he slomocn.

15

The hollow vtscerc ,:c""",ued Look at (Fig. 1.7):

• • •

How the barium FIl.IC.lb in tht' fundus, l'\,IClly dS the I'{';.ting g.,l'>tric juiC'l' Jr".'" on the plain film The largoamount of ~,l;. present, again in thl' body of the stomach. The patient has in fact been given effl'r\'l~t'nt powder to generate excv-s carbon dioxide to distend tht' stomach and generate 'd ouble contrast', i.e. an outline (If the mucosa with barium and 1\.ls. How the fundus is seen only in 'single wntr.lst' on thiv view, i.e. barium alone.

look for the small bowel Because of f'l'fistal~i-s the outlinl' of the gils in thl' normal small bowel ts often broken up into m,my small plll.'kl·ts which form plilygon,ll shapes, but oCCUpy.l gt'llt'ralJy central location in the abdomen. when more distended, the cbaractertsnc'valvulaeconmventes', \,rroilloJ spring-shaped folds ,CT(l!'sing theenttre lumen

1Tlily be seen in the jejunum, although the normal ileum tends to remaln fl'dtull'l""s. The calibre tlf the normal small bowel should not exceed 2.Scm-3cm, increa..ing slightly dhot,llly.

Often wry little is seen (If till' small bowel on plain films. ,1S ill Figure 1.1 , and it only becomes well visualised when abnormal.

16

The hollow viscera

COIlhn.-l

Barium pooling in fvndus

Gas in 00dy of stomach

Fig 1.7- This is a spal1iIm from a barium meal study with the patient supineeJl,octIy some paSltiotl os thepreceding film.

me

17

The hollow viscera cor>,inuttd took for the cppendix 'rou'Ilbclucky to find it!Occasionally this strurture w ill contain ,111 'appendicolith" [i.e. calcified fM'C.11 m.ltl'rial) which may predispose the pauem to appendicitis Lee, commonly ~.h will be pn....en t in the appt'ndi\, someurne, barium from a recent Gl st udy, or even piece, of lead sho t which have been ingest ec'! and Impacted themselves there. If you see this (Fi~. 1.8) you ran then have a Iittlt' bit of amusement with your patients, who will be amazed to know how you have figured out from their abdominal X-rJY that tlwy have rec ently eaten g.lm", (t'K.1 rabbit or a pheasant). Note: Retained barium in the appt.'ndi\ nnphcs the previous 'ldminblrd\inn of barium, either otdlly or pt'r rectum. and implies su- pected GI tract disease. If bar ium l'nh'rs the ap pendix. however, it implies that this mg,m is normal.

I Fig.1.8-Leodsholinopperldix 18

The hollow viscera con';n.-}

look for the colo n [Figs 1. I and 1.9 ) 1. Start with thecaecum in the ri~h l IliacfllS';'l. The-caecum ts the most dbll'nsib ll' part of the colon and rec eives tluid material directlv from tht' ileum th Rlu ~h the ileocaecal vain', The caecu m therefore nermallv contains semifl uid mater ial nmta i nin~ mulliplt' pockets of gJ.sand , like much of the right sid",of the bowel, assumes a gr,m ular ,1ppt>ilranCI' on X-rJYS, creating mottled a n ',lS of g.Js....-en best .lg,lin:-I the background of the iliac bo ne. On occasions the normal caecum rruy be l'mpty. 2. ,\8 The classic anJltl rnka ll,lyout of the colon j..; otten fnumi In ht> dt'\'i.lll't'! from by tortuous and red undant bo.....el, but the hepatic and splenic flexure, ..huukl be idl'nli fi.lblt' ,IS the highl~1 fhed fltlint" on the right and lett ..idl;"'>, n"'pt'cti\"t>ly. The tu n!,>\'t'!'>t· colon m.ay dip down dt't'ply into the pt'1\"i!'> , but lilt' faecal content of the bowl'! become, increasingly solid and formed as on,' pas"t's distally, eventuallv generati ng d iscrete masses which may be indi\iJually idt>nlifit.J, but which always contain m.an y tiny POI:k!S gas. 3. Learn 10 idl'T\tify faecal material on abdominal X-r.l}'S tsee Fig. 3.1 01. Find tlro t and you've found the ([I/,m, which m.ay be w ry important in film analysis, particularly in diffen'fltiilting sm.all bowel from large bowel, These findin~s can best No appreda red in severe «>nstif'iltinn with gnlSs faecal overload . Somt'timt'S thb "ill involve the rectum (which is usually t'ITlpty in normal iodi\iduals), when a 1.1~1' fat'Cal plug m.ay be present as...·..ociated with overflow teconnnence. .I. When visible the hdust ral fulds ,If the colon may be seen, only p.1rtially \isualin.J acn....... part of the Ia~t' bowel lumen, although in ..... une P.lti''flts Clllllpll'te en....sing of the lumen toy haustra m.ayoccur.

,.f

19

The AP e rect film Under the otfects of ~ravity much ch,ln~t>S wh en an abdominal X-ray ts taken in the erect posi tion . The m,l ~ ,r events ,lll': • • •

• • • •

•

Air rist's Fluid sinks Kidn c ys drop Transverse colon drops

Small bowel drops Bm1sls drop (f~'mall'S: they 1i... laterally when supilll') L ower abdomen bulge, and Increases in X-r,ly dt' nsity Diaphragm descends {"lusing increased cla rity of lung bases.

The liver and spleen, being fixed , ten d 10 become more vtstble, the remaining mid and lower abdominal contents It">s so. wbvn the lower abdomen bulge, under gr,wi ty this reduces the dartty of its rontvn ts owing tn th e crowd ing togeth~'r of 1'f1;ans a nd the consequent increased dt'ns ily of the Sllft tiSSUI'S. Depending on the I,ri¢n,ll lll'igh t uf the colon and their nwn decent in the "'TKI positiun, tIll' kidneys may become more or II'Ss visible. The erect film, however, I1MY now show flu id level.. (sl'l' Fig. 3_4), which can be wry helpful in con firming the didgnnsis of obstruct ion and ,1bsn'Ssl's, hut fluid levels on normal films tend to be \'ery small or invisible. In pcrforatton tlf the bowel an erect film may confirm a pncumoperuoncum, when g,lS has risen to the cla ssic suhdiaphrdgm
• •

• • •

The 'rercr' marker over T i l Th e ut'pt'nden l pos ition of the broast-, c,lusing increased densities over the right and left upper quadrants. Do not mista ke these for the live r OT splcen -. their l'llgt"> p.1..... I,ller,1Ily beyond the ronfines ~If the abdomen The ~)S in the g,lStriC fundus - typical tlf the erect ptlSition Small quantitil'S of trapped f;
pelvt.. •

20

The position llf the colon. which has dropped u nder gravuy, end bulging of the lower abdomen ,lntl'riorly, cau..ing the incrl',hl'li u l'nsity in tht' ItlWI'T third of the abdomen ,UlU nb",:uTinloi till' 'lll
The AP erect film

conlinued

Gas in fundus of stomach

I

Breast edges

Gastric rugal folds in body 01 stomach low lying transverse colon

Increased densityof lower odbomen Faecal matter in colon

Fig. 1.9 - This is a rypical normal erec t abdominal radiograph of a female polien' butthere is insufficient fluid to form Fluid levels.

21

Calcified structures look for normal calc ifie d struc tures Learn to rt'(l ~nil.e the follo w ing structun-s.w hich ca n nnmlJll y calcity and cau se diagm)<;tic contusion: Costalcarttlage, may be mistaken fOT ..... Biliar y and Tl'n<11 calculi

Hepatic and spll'nic ralrifiration Old T8 in lung h..l~'" Aorta mol y be mista ken for

.

Aortic anl'UT)"'m (if tortuou s or bent)

lll,rc arteries m,ly be mist,lk l'n for

lliac ,ml'urysms (if tortuous or Pt'nt)

Splenic Mll'ry, 'The Ch inl......• dragon sign', may be mistaken for.

Splen tc artery ,1lll'UrySms

l'elvtc phleboliths may N' rrnstaken for .. Urete ric/ bladder calculi

Mesenteric lymph nodes m,ly be mistaken for

.

.... Renal yun-tcnc calcuh /sclerotic bone Il'Sions

over spinl' / Silcru m / ilium.

Red fan 'S ,111 round and serious mnSt"ljUl'nn'S for the lThly

p.rtu-nt from

misdiagnosis

occur from misin tl'rr!\'!ing these normal findings. Don'tlee it happen to .VOlt!

Cos tol l eartltages On abdominal and ches t X· rays look atthe rib ends. In m,my patients they oflen ap pear to stop sud denly and nothing is St"l'n (If the cosu! c,lrlil,lges. Keep looking, however; an d in others a contmuauon of the ribs will cll'dTly ht· seen , Thi s can be marginal, hl"Wy and detinctive in mak-s.or mort> punctateand cent ral ill fl'lllilles, and the phenomenon increases with agl-', bUI lIcc,lsiollally can be startlingl y heavy in the young. Look ilt (Fig. 1.l0l:

•

The multipll' dense fo ci Il W T the uppt.·r and middl l' abdomen. This is cos tal car lil,l gl' calcifica tion . ..... hich both s imula tes ,1nJ ca n obscure gen uine assooatcd areas of calcifica tion in tht' underlying l'r~,ln~. such ,1STil or calculi in till' liver, kidneys or -phen.

Wh.iltn dll ?Obliqul' films, It 'ml~r,l mS{lr CT sca nning m,ly be required lor fu rther elucidation OTIht· exchrsion of ralculi. Tnmngr,lms ,Ul' X' T,l y films which seb-ct out slices.lI dif fl'rl'nt II'Vt'! S and blur the b.u-kgrounds.

22

Calcified structures 1;0<11"'.-1

I

Artefoc!

Ccsrcl cartilage cokifico~on I

[ Fig. 1. IO-AProdiogroph 0 ' 0 15·yeor-old womon.

23

Cclcthed

structure s con ~nued

Acrtc LOllk ,lI IFig_ l .l l l; •

•

• •

•

24

The calci fied aorta OH'r the lumbar spinc. d h 'idi nKat the in ferior body of L4 into the iliac arteries, w hich cross L5 an d bo th sacral wings. You will o ften also see interru pted linear calctfira no n in both walls (.f the common and external ili,l( arteries. whic h may continue dCWSS the true pelvis to the femoral a rteries in the groins, reprfN.·nli nj!; artertosclerotic cha nges . With increasing aj!;e the aorta shows incf(w..ed calcification, JUst like the aortic knuck le in the chest, and starts to become visible over the aK\' (.f -1(1. Look carefully o ve r t he lumba r sp ine a re,1 for flecks of parallel or slightly converging plaques of calcificat ion w hich may be seen: you musl train yo\Usl'lf to look for th is routi nely on I'very film in nrd er to exclude .10 anl'urysm. Be c,u d ul, however. nnl to mista ke ,I curving osteophyte in an osteoarthritic spine for the aorta or an ant·urysm. In ';(lnw patients the aorta (,10 become tortuous and bent to the left or the right of the spi ne, but withoutbecoming aneurysmal. Look at both calc ified wa lls for loss of p.nallelism before d i agn~ i ng an aOl'urysffi. as simple tortuous vesselsand ,1nt>urysms can luu k likeeach other. Note the age nf ('wry patient carefully. Premature calci fication in the aorta can be a very significant medical finding - t'_g_ in diabetes or chronic renal failure- and is nnt always due 10 physiological changes of ageing.

Calcified structures conlinved Calcified aor ta

I

Point of d ivision of aorta

Calci~ed L common iliac a rtery

fig, 1. I I - Supine APradiograph of a 68-year-old woman.

25

Ca lcif ied sn ucfures contotwe
I

Phlebclnhs Fig. J. 12 - APview 01the pelvi5 in 0 53-year-old womon.

26

Ca lcified snuctores """",1Htd Look at (Fig. 1.13): • The ~lTIdll of'ilcily in the Ltrue pelvis: r hld lt.lith or calculus? Arontn.[ film rp. 2l'l) hoi.. 'ot.'wT,tl rurp..~·" : • To try 10klCatl' tm.· ptl!oition of tht> kidnl'y" before injection • ToIOllk fliT calculi • Tot'\c1 uJl' In aort ic d nl'ury~ m - compres-lon hy J light belt is otten applied acrose. tht- Iow er abdomen Juring IVU." hUI not in renal colic, oIhl'T acute abd('rnt>n,>, postoperative ~IJt~ or Irauma. The pUTpost' is to prevent in.ldwrtl'llt mmpreo-ion ulan aneurysm • To dt'Olt.ru.trdlt' ,IllY incidt'l\tdlfinJin~ • Tod'lt'd. the Tadiovaphic and pn..."\"!t.'Ioingquality prilll" to tlwocontra-.t injt'\:tillfl and t.Jking 01. turtht'f film.. • To b.j,;, for t"\idl'OCt' of meta..td~ in ..uspected malign.tncy.

27

Calcified strud\J res rotItintoed

fig . I.' 3 - This is Ifte supineAPradiograph ofa 4.>yeor-old mole who piesented with suspected Lrenol colic. Urologists refer 10 such radiographs cs 'KU8' films, for Kidneys, Urelers ondBIodder. Other names irdxie 'scour' films and'PRELIM' films, but thecorrect rodiogicallefm is a 'CONTROl' film. Th is means on X-roy token 10 cssess the potient before ony controst medivm hosbeen given. 28

Cckilied structures t;OtlImw
Fig. I. 14- Same parient Following theiniection of con/rosl. Nore how the left ureter has bypassedthe pelvicopacity, which is now shownnot to be a colculus bvtaphlebolith. The cause of the patient's pain was at a much higherlevel. t.e. the left pelviureteric junction, which is narrowed and causing dilatation {trydrorepnrosis} 01 theleftrenal pelvis. 29

Calcified structures COfI"n..-i Splenic artery The splenic artery may only be intermittently calcified , the di'loCOntinuity making il mort' difficult 10 identify its true nature than in Figure 1.15. Partial ~plenic arterial calcification musl not be misinterpreted as a splenic arterv anl'Urysm. Do not mistake it for n'MI artery calcific,lliun: this may of course coens t and will often be present bilaterally, but usually only the splemc artery shows ..uch a deg ree of tortuc....ity a" it wend" its way towa rds the spl enic hilum. Heavy un'rlying costal cartil'lg\' calcification (Fig. 1.15) m,l y make it difficult to isolate the splenic arterial calrlfiration.

30

Calcifi ed structures conlinwod

Fig ' ./5 - C4kifiecJ splenic artery This is the left upper quadrant af a l8·yeaf. old woman. No/e /he serpiginous paralle~wolled calcified lesion intheleft Rank, resembling 0 'iumping jack' firework or 'Chinese dragon' extending towards /he hilum of /he spleen. This is the splenic ortery.

31

Calci fied structures continued Calcified lymph nodes Look at

•

• •

( Fi ~.

\.16):

The inciden tal finding of a collection of granular opacities in the flanks The pa rtially coalescent cluster of opacities ove r the L3/ 4/ 5 lumbar sp ine levels Some furthe r small opacities in the epigastrium.

These are calcified lymph nodes. Usually the p<1lient is asymptomatic in regard to these. Lying in the mesentery they tend to be quite mobile and show dramatic changes in posi tion from film to film. Con versely, an apparently sclerotic lesion in a lumbar vertebra can be shown by an erect or slightly rotated oblique film to be mobile an d due 10an overlying calcified lymph node . Always remember that on an X-ray you aft' ll)\,king ,1t three-dimensional structures lying on top of each other shown in only two dimensions. Calcified mesente ric lymph nodes are often attributed 10 previous ingesnon of T6 bacilli to the gut , which han- been halted at the regional lymph no...Jes. On occasion they will require 10 be excluded ,1 n-nal or ureteric calculi, and can be a real diagnostic nuisance, NB Calcified rdrol'l'rillHlm{ lymph nodes, or such nodes opacified by con trast medium at lymp hogrilp hy, may also overlie the spine but show less relative motion, being wry posterior. Calcified nudes r.....[uire to bt' differentiated from calculi and calcification in underlying organs righ t alongside the sp inl' or iliac vessels.

32

Calcified structures ron hnued

F'9. I .' 6 - This is a supine APabdominal radiograph of 0 45-year-old mole Xroyed for obdominal poin.

33

Decubitus films A word about decubitus film~ (Fig_ 3 .9)

•

The Latin word dl'CI4f!itl4s comes from the Latin dt'Cl4mfttTt: 'to lie down '.like~ Roman pat r ician lyin~ on lus side eating at a banquet , and mean~ with the pa tient lying on his left or right side, Ib puTJ'l~t" is 10 obta in further informa tion, such as confirma tion I,f a "mall amoun t of free ga!', or to demonstrate fluid levels in a panent too ill to be sat up. A horizontal en",... table beam is used rather tha n the us ua l vertica l bea m fro m overhead for

•

•

"urine films. Such films require wry close and careful interpretation and should not boo taken blindly without a wry clea r ide,l of what is beini'i sou ght, usually in r on pm rt ion with thl' radiologi "l, or ,IS <1 reasonable alternative toan erect view for the radiogrJpher. Such films, however, ma y be w ry valuable and clmc h tht, d iagno" is - if :; or 10 minutes MI' spe nt with the patient ill the J ppmprid te pt~i tioll to allow .:my free ga~ 10 track up to the flank. If you take it too ea rly yllU ma;.-miss the gas, as Ihto a mo un t ts so metimes wry small Decu bitus films can he idenrified by fluid Il,\·t·l.-. l:-ing potrallel to the klfigaTh of the body, as opposed 10 al righl-a nglt"S to It o n conventional erect films (see film of the screeum on p. 7 1). ~· an-al..... used routinely d uri ng«lO\'entionai bartumenema exa minations, and todemonstrate free pleural fluid in the cht-st. c.g.to differentiate a 'subpu tmora ry' effu..ion fmm a raised hemidiaphragm and 10optlmilt,thl' view of the uppermost lung bases in patients wh o cannot inspire fully.

N il A 'rig ht decubitus' means the patient i!' lying with his right sidl' down. A 'lett decubitus" means the ~'l,1 lien t is lyin g with his left side down. For technical reasorrs decubitus films lend to clime out wry dark (i.e. over exptl'!llod) and frequently require bright lig hts behind them III allow them to be

..tudied properl y The y a ll' best shJ n-d with , and interpreted by the radiologist at thl' timr they aTl' faUn . Getting a report of a perforation (whic h you have mis~) the next da ~'

when the pati ent i.. dead is too late.

Cater 2

Solid organs

•

•

•

like ft't't and noses, IiVl' r.. ro me in differen t ~ hapt.'S and SiZl'S. J U ~I as ,1 liver m.ly .lppt'.u to be significantly enlarged clinicall y by palpation . it Ol d y also 11Il,k enlarged on an abdominal X-r,ly when in fact neither is the case, and such aeessrnent is often suhjl'... tive. Asaln'ddy ml'nlionoo,lin'("S pushed down by lun~s rhronkally overinflated by chronic obs tructive pu lmouary diSt',l'iot' , or hdving an alldlomica lly more t'\ lensiw right lobt, (set;> Fig !i.l'lt can both create th is illusion, and these film must be remembe red . CllIlVt'fSl.'ly, true ht'patumeg,lly mus t be suspected when there is evidence {If displacement of adjacent o rg,lnS or, i1S d rough ~uidl" when 1I'll' lengt h (If the liver exceeds arou nd 16 em from the dpt'\ (If the right hernidiaph ragrn in th e pa rils,lgi ttal pla ne. b u t clinica l and radiological finding-, may not concu r, Liver I'nldrgl'nwnt is of WUf>;l' a very mm-~f".'Cific sign. and serves only as a reason for Idunf hing furlhl'r i n \'l'sligati o n~ of both hwr function lin d imaging - usudlly ultrasound to l>t.ogin with.

35

Big liver conh" ued

Tip of liver

leh kidney silting high

Fig_ 2. I - Abdominal rodiogroph of0 6B.yeor-old womon with 0 large palpable mOSl in the Rside ortheabdomen.

Look Jt

( Fi~.

2.1):

•

The hU~l' md~~ in the R side of the abdomen reaching to the lewl of the iliac

•

•

11k' absence of pit in the R side of the abdomen which has been dbpldn...:! Tnt' increased densitv of the R slde (If the abdomen

•

Tnt' rou nded contigu ration

C"-'!>I

Il f

the lower edge of tilt' mass

• Tht' l'n tin- margi n of the norma l R kid nt'y remaining c1t'olrly preserved sur n,un"li ng foil, indicati ng that the mass is not renal •

•

36

Th e R ma rke r confi rming this is wnsislt'nl wi th the liver The left kidrll'y sitting high tu pper m.l r~in n 11.

tty ib

Big liver cOtl,inV
The main Cd U-.es are: ~l.ilign.tnt

~1<'td ..Ll,*'S, hepatoma,

~letabolic "'ord~t' di'ot'd'it'!'o

Glywgl'n, amyloid , fat

InfLJ.mmatory CiJThoo;is V.lSCULn Hat>m.ltological

Ht'p.ltitis.
chotangiocamnoma

f...lrl~·

~l yl'l"fit>n'Si<;.

leukaemia

Small liver TIlt.' liver may look 10 be on the small side and yet be normal anatomically and tunetitlllilllv, e.g. in a small individual, and declaring a liver to be pathnk~cally Wunken from a pl.lin abdominal X-ray to, MI normally attempted . Asecondary effect uf shrinkage tlf the liver, however, may be that a loop of rolon - or. It...... frequt·ntly. small bowl'! - may slip above it and become visible directlv beneath the right ht'midiaphraf;TTl Isee Colonic intt'f'JXlSititm. Fig. -1.5). Tht.
Alcohol Hefldtihs Drugs Obstruction. 37

Small liver conlinued

Coexisting enla rg emen t of the s pleen m,ly occ ur, with associated po rtal

hypertension. Big spleen Frequently the spleen cannot be see n on ,111 abd ominal X· ray. Wh~n enlarged (> l 5<::m ), ,lS with other int ra-abdominal masses , this is detected by an increa se in size and dl'nsity, and by displ.lO.'nwnt of .ld~lrt'nl structures. A norma l -pteen can indentthe h-lt kidnt'y, causin g a 'splenic hump' just below tht' point of cont act (which must not he mistaken for a trot' renal swd ling),an d sm,11I ,1a.:I'Ssory sp lt"'ns can someti me, be presen t. NBQ XilSiolMlly d f'<'til'nt will h.1W11\1 splt"' n, dueeither to con genita l absence or surgical1"l.'mm '.11. Spll'1l0ml'g,lly can, however, be enormous. t'Sperially when the patient com es late In medical attention. This finding, like hl·PJ.tumef;i1ly, is nun-specific and has ma ny C,l USt.'S. Look for (Fig. 2.21: • • • • • • to

38

A soft tis~ut' mass eXlending downwards and medially from the left u pper qua dranl Elevation of the lett hernidla ph ragrn Media l displ.rcement (If the stomach Downward . Hsplacement of the Id l kidnt'y Inferior di splacement o f thecolon h 'idt'nn' l,f a-sodated liver t'nl.lrgem,,'nt,l nd lymph nud l, t'nl,u genwnt. N B Occa-koolly the spleen will enIMl;l' st.'II'C tively down the (j) flank l.lll·ral the © kidney,

Big spleen

Stomach di5 placed to right side of abdomen

,

t:Otlt.",.-J

Elevated left hemidiopnrogm

Spleen Fig. 2.2 - ~ mis is the film ofon ocJult Iemole who presented with

~Iized ill heol,rand 0 large mon in the leN upper abdomen. Examination C/ the blood showed changes oIle!"koemio. The man wos shown on uJlrosounJ b be a soJeen. The liver wos noI enlarged. Note the R marker ;U5t visible the rop reFt-~ond corner of the him,

0'

croe

39

Big spleen conhnued

Causes of spleno megaly Trauma Infection

Ruptureof splt't'n, causing olpf'drt.'lll splt"llumt"gal}' from a subcapsular haematorna Acute: Infectiuus mononucleosis lntective endocarditis Chronic: TB Bruct'llosb

IlIV Neoplas m Lymp homatous I I,lI'matolngi cal

Molldria Secondaries from bronchus, breast, gu t. pruSI.llc Hod gkins' diSt.',lst' Non- Hodgkins' dist'd"t' Leu kaemia

Polycyth,lt'mid ~ln'losdt'n,.,is

Storage disl.mJeN rurtJl hYJ't'l1elbitlO Cystic masses

Others

Haemolytic anaemia Caucher's diSt'ol'>t.' Polycystic di....aSl' Hydatid cyst Developmental cysh Rheumatoid Amyloid Sarcoid Cottagen vascular diseases

Big kidney, Nutt' (Fig. 23):

• •

The bulkv tout SIIl
•

These kid n ~ extend from the Urpt>f margi n {IfTI2 on the left to the upf't'T margin t.f 1..1 on tht, right. (If 4.5 vertebral bodh-, (and discs) in this patient.

di~)

40

Big kidneys CDnlt.....d

• fig. 2.3 - Enlarged kidneys This ;s the film of 0 patient pre5efltir1J::tolly

WIth symp/Oms and signs of 0CIJIe glomerulonephritis with M ,

profein in the urine.

and

41

Big kid neys COIIh"..,.d •

•

Kidneys vary in ..in' and shape and the It'llone is usually !io lightly 1.H~l:'T than the right by up to 1.5 em, although 01 duple kidney Ii.e. one with a double drainage sy.,.tl'm ) ffidy look abnormajly big but still be hislolugicdlly normal. Kidney!oareusuall y 1J.rgl;'!' in men than in women, and each individual kid~· shou ld ooll\l..rtrLdlly lit> more tha n about 3.5 vertebral bone, long, including the intervening lumbar discs in a gin-n patient, measured in their long axes. i.e. from pole to pole inclined towards tho spine. Kid neys over 12 em and under 9 em aft' usually rega rded .IS pat holog tcally lugl' and small, respectively Kid neys in young child ren normally 'lppear dbpwJ'llrliolli1tdy

•

•

•

lafl:;t' just as the liver d ot'S. Bilaterally enlarged lIT unil,llerall y l'nl,lTgl'd kidneys ffid y be pn'SI'111 with one normal sizeor shrunkenon the cllntr,ll,l lt'fal side. Enlargemt.'nt of 1',ICh kidnev TThly ,1\s.O be generalized d ue to global di"t'd"t' or :-.tlmething mort' focal, such as a cyst tumou r or loc ali zed hyper trophy. So..c alled co mpensatory hypertrophy of a n'llldining kidnt'y m.1Y abo occur if the other one reases to function or is removed, but this re.pvn'>t' reduces in the e1dt'rly. The importance of detecting Iargt' kid~ is that then> Illdy be tht' potential for recon .'I)' when Ihisfinding ~a!'..o;ociatt'\l with renal failure, although biopsy will be required for definitive d ia~nosis, almos t invariably preceded lly ultrasou nd to belp exclude renal ooserucnon and dSse-;S the parenchyma. Converse ly, sma ll kidneys usually reflec t end .....tage renal d i"t'o1'>t.' and an irreversible stall' , making biopsy somewha t acad emic and putentiallv hazardous.

•

Loo k carefully 10 0 ,It the edges of ttwkidlWYS. whether smoafh, lobulated or n regulae - important points in differential di,lgnosis.

Causes of bi laleral big kidneys •

Acu te glomerulonephritis

• • • • •

Diabetic renal diseolse (glomerulo·;clt>n",is) Adult polycystic disease Acute tubula r necrosis Acute cortical necrosis Bilateral acute pydonephritis

•

Leukae micinfiltration

•

Lymphomatous infiltralion

42

Big kidneys con r",ued • Amyloid • StorondJry I'm ,11 d i ~\N' in gout. • E\(~siw beer drink.i n~ - medical"tudl'nls I'II'J"'" noll'! Somt

uu~

of un ilollt'u l big Idd nt'y

Acuteobsnuctum Acutt.' inf.m1itm : I'\'fldl drtl-ry rcctu..ion, renal win thrombosis Acutt.' I'yt.'lllnt-phnli.. • lUdi.ltion rwphrili.; • Dupk-x s~...ten • Compl"lbdillry hypt'rtnlphy from contralateral nt'f'hl'\-'ctl>my (If dysfuncti<m

• • •

•

Rrn.al~.

Small kidn. s ~ing ltwo ~ l>f ..mallk.iJ~'$ may be \~. dlffJruIt or imf'l.... sibk onpLun filnb(lYoinf; tooverlying f,lt'CIOS ill1o.1 ~s. H,IWel.W. if the J'dtit'flli5 cll'arly Mn"t'.md not Ill'I di.lI\·5is th..-n- mu-..t be functioninp; M\a11bMJt> SllRk'wfwno. anoJ OC'Gbion.llly it b vbiblt.'. gememben The lidnl"p shrink. or dlrophy with age, compcnsatorv hypt·rtrorhy ma~' nlllllccur III Iht' ddl'fly, and X·ray measurements will d lwa~'5 grve .. :»-25 maf;nificali(lfl. so lhoil X-ray IDt.'a-'iUl'\"ml"Ilb will alwaY'" be Lugt'l" ttwn Sl1"t"> obtdined lin ultra..o cnd, CT or MRI examinations, fr.r t'U mpil'; IIX' if'PdT'l"nl Sill' Ilf the kid nt'Ys may also mcrease even moll' afte r i.v. co ntra-,l oIdmllu.'.tTation fill' I\'Us.

UUW'\ of smolU kidntys

• Chrome glllml·rultl'>Cll·n....is (u.;u.llly biL.lll'rall • Chronic i.'oChal"mi.l kg. n'fldl drtt-ry SII'f1llSis, drtl'rio~is) • Chn:mic pyd orlt'ph rili.. • Rdlu, nt'J'hnlp.llhy

• lniarction • St'llill' alnlpy • (ongl'n il.ll hYf'lll'lM.iil (u..uall~· unilatcrall,

Con g enital renal abnormalitie s NH Alw ays rem emb er that an unknown pati ent may have o nl y one fu nclioning kid ney, Thb i!> t"-pt'\"ially important when invt"!>tiRdtin~ trauma: mort" than one p.l til'nt in medi cal hish,ry has hod his only kidney taken ou t, and kid neys have a remarkable capacity for ht"l lin~ ,1Ild regen eration. ~ B A patient who is known 10have only one funct ioni ng k id ney And wh o is pAssing urine Cdnnol be complete ly obstructed. This is somcurnes forgotten by young doctors requesnng 'urgen t' IVUs for '? obstruction ' when rme kido l'y hac been removed.

Two importa nt co ng e nital re na l abno rma litie s Pel vic kidneys when inVt"Slig.llions fail to demonst rate kidneys in the renal bt>.Js, Olle or more tlf them is usually found at a lower level in Ih,' pelvl...This is called an ectopic kidney (Gn't'k ,'k, out of, ttl/JOs, place). Inflamed pd vic kidneys C,lO simulate appendicitis or gyn,lt'colog ic,ll probte ms. Rem ember: transplanted kidnt')"S mol Y be put into Iht' pelvis and even a norm,l lly sited Id d nl'y m,ly be invisible.

Horseshoe kidn eys These C.1I1 som etim es hi' sus pected or di,lgmN;'l.1 on plain films. Tlwy tend 10 lit' lower than normal and tend to I,Kk the usual medial mclmation relative Itl the spine .11 their uppt'r poll~. TIll' pathognomonic r,ldiologkal sigo is 10 WI' the rena l cortices of the lower kid neys crossing the margins of thl' IlSods muscles medid lly to connect with the etfu-r "idt' , This part of a horseshoe kidney system is known rlS the ist hmus. The d r,lin,lgI' sys ll'ms in this condition tend 10 be m..rlrota ted forwards. The isthmu.. may contain euher functioning "I' just fibrou s tissue. Look at (Fig. H):

• •

"

The cortical margin.. of the kidnt'y .. m~siog the p SO,l S muscle, The ,lSSl.lCialt-.J developmental spinal anum,lly ,1IIh(' Ll /4 levelon the ll'ft and the <,clllit)Sis convex to tht' left.

Coogenital renal cbnoemcbnes

conhnued

Renal cortex crossing the pscos muscle

I Fig.24-Hof$eshoekidneys

Congenital renal abnormalities conbnved

Fig_2.5 - Iiotw~ kidneys Somepotienl following i.v. conlrost confirming

horseshoe Hdneys.

46

Co ngenilal renal abnor ma lities COrI,in..-:!

\..ol.lk 011 (Fig, 2.51: •

The abnor mal lu"'t'li renal

rtlllt":lin~ ~y~ll'm~ llH'rlyin~

the spine a nd the

i'lhmu~

•

Ibe IT\dITllt.llt'ti righllidnt'y with itv colltorting ~y!>tt'm fdcing antero-latcr... lly in!>lt'dd of mt,Ji.111y"

Compliulion!O HtJf!ol'!;OOt> kidnl'Y~drt' mon- !ow>I.""t'ptiblt'ltJ infection, !otonl' formation ...nd trauma. TlJto holhmu!o m.JY a1o.tl gt"t in 1l14.' WdY in rdditilOOdPY planning" HtlN.oshtlt, lidtll'\"S 1J'\oI\' occur in TuTT'll"r's svndn>mt".

RInGI mau e , RrNI trId~'ol'S m.JY be ftlund during Iht>

inn~ti~h(ln

of a pdtimt "';lh UriIldIJ'

troJd !oymptnm..., such d~ haematuria, ur as an incidt"TIldl finding when Iht> p.1lil'lll ~Mng X-rd~'oo It)!" .;onwocht.>r purptl'>l'. e.g. bdckdchE-, but t'\"m d larp' orw m.J~'

lIP Ul\bihko en d Stdnddro. him"A sigmfKdnt M\dl m.JS'" m.JY

ht.lWt>\"t>r.

• IX'IVl1 the pt",ilivn t>l tilt.' dnlic1p.ttl,J renal t",Uinl' • Actu.1Uy d~spl.-.ct-Iht' lid~' mlm which itdn_ • Di.'f'LKt' tI\"t"rl~;ng ga.....contdining Iotlf'!' (I{ bowel •

Cn....!> the mdlme tothe tJppt"'itl' vide.

j-Lning dt'tl"Ctlod d m.J.... Iht> prlm.Jry rt'lIU1ll"llll'llt is Iht'n 10 t'!>tdblbh wht.:"tht'r it ill 'oll/id or C}...uc. and thiv can usudlly bt.> t'a~ily achwnod with ultrasound. Furtht"l"

urt'lul inspt'ctitln of tht' plain films in the initi.ll phase, however, III Illtlk for ll~" of pso.ls tlullint'" or buny d~tructitln of pdrt Ilf a vertebra. md)' indicatl' IN!i~ncy hum thl.' ooh...t" ull"king intn the lung ba_ on dn sbdorrunal X-rdY may also 1m ceca..ion 1\'\"1',11pulmon.m - meta..la......., a nd ..hould be routine on all abdomin.al X·rdy"wht'1'l.'lht""l' are vi..ible, althnugh d full rbc...1 X-ray will al",a dy be indicalt'ti. The nextta..l i.. ~Idging with CT 1,lthl' ma-s. MRI etc.

47

Renol moues conlirwed

Fig 2.6 - CIoHHlp view from obdominol him of [Honk in 0 56-year-old mole presenting with backache.

Renol messes

COI'Ih nued

This p..ltil'nt lR);_ 2.f1l initi,llly had hb lumb ar sp ine and abdomen x-rayed to look for a cause fur his bJd,al' hl·. Ap•art from minor dl1\l'nl·r.1tive change no ~I abnllnn.llity was found, but can- lu i i"-~f"'("tion of the film showed the edge of a large In.l'" in the It'll flank w hich was cle.uly 100 big 10 rep resen t part of a nOl11lJJ kidney. An ultra ...>U nd scan ronfirmed a solid ma"s arising from tht' Il'tt kidl'lt'~·_ On billf'!"Y this w a.. found to be a nm.al carcinoma.

\I oral: Do nol confine youl"'O(' lf to th e area o f p rimuy interest alone e n an X-r.y film. bullook ••• 11 of it. Alw.y be ready for the unespected Incidental finding.

A word about 'd isplaci ng mosses' {ll\~y

an .bnormal ma".. can an.... anywtwn> .00 it'> ~t'1lt"I"al effect will be eeseee. i.e. to produce a dt'll'>l;' area with di<,plaCl'fTlt'llt of bowel loop-, around It. Sophi~icatl"d in\·~ligdlion .. y,'ill boo' nt'(l"'!oSd.~ · In l"'!olablish the evact cause 1Wtn.'>OtJI'IJ. CT, 'IRI, barium rid. ShoulJ the ma .." It~f contain a lot of gas thi.. ",'in usually indicate part ot the bowel il....·1f te.g. \'ulvulusl o r f"'Thdp!io an al>sce.... 1J.t't" Fip ·U3 and -un The den..ily ul a mas .. may also be inrn"a~ by the f'l'l'Sl'N" at caldficdtion y,'ithin II.

49

Pelvic masses The urinary b ladder In p ractice tht' most common reason for findin ~ a la rgl' 1J1d"~ tin X-ray in the pelvis i" a full bladder (Fig, l.l), and ther e arl' a number of rt'.Nlns for th is:

1. Paucnts often han' to wait to be brought to X-ray and their t"ran"it molY be del.wed . 2. Further w,liling pt.·n ods <11\' com mon in busy X-ray dt' f...art mcnes. 1 Somt' pa lit'nts will have genuine outflow obstruc tion, e.g . .lUI.' to p rustatic d i....-ase, ,mJ be unable til empt y Iht'ir bladders compll'ldy. Some patients who com,' back fOT KUlJ films and renal u ltrasound are spt'Cifically asked 10 attend with a full bladder. In s''l' ldng lhe bladder, look for: • A smoo th rounded or tran'!>wl"ol'ly orientated oval m,h'!> of uniform dl'nsily in tilt' pelvis. lts outline , when visible, is d ue 10 perivesical fat (st.'I;' Fig. 1.1) • Upward di" pLll'emen t tlf small bowl'! loops. which ,1I't ' h\'d y mobi le and can (,.lsily be shi fted com pletely {lui of the pelvis

•

hn>o;sin' indentations in add ilion Itl the normal ones ("igmt.id ,lOti uterus! ca used by p'llhologicdlly l'nl'll);l-'d masses (('.g. fihJ'tlids) (' T faeca l overload.

Common caus es of p elvic mass es • • •

I'h ysinlog icall y full bladd..r: ma ll' or fl'mall' I'dihologicrl ily full blad d er indica ting outflow obs truction. ('.g. prostate in an "dull male or a blocked catheter in a female Bulky u terus (pn'gn,lncy) -111I,k fur fCl,d P.lfts' Did you check tlu- LMl' (1,1.,\

menstrual ~ritJoJ l bt>tnn' TetJul'Sting this film? The majority of slgntfkant abnormal pelvic ma sses occur in females, includi ng: • Leuun yomas - fibroid s, often calcified • •

Ovarian cysts - can be the Sill' of a footba ll Ova n an tumours (be nig n or ma lign.ml l

•

Pelvic infla mmatory d1>eo1 >;('/,Ibscl>o;""'"

•

Haemalnmetra (blood collect ion in uterus !

• •

End umetrtosis Haema toc olpos (blood collection behin d imperforate hymt·n l

•

Dermoids, containing f'll, teeth, hair.

50

Pelvic mosses conIi....d

Fig. 2.7 - AP pelvis: /VU examination, bladder area. Look at /he effed of a

ItUge pelvic mou severely compressing the bladder From above. This 00'0I'i0n cyst. It is alsoporliolly obslrvcting

was on

baf., ureret-s.

x on-gynaecologi cal • Al;>:;(t~ from dpr'lmJix, diverticula, lvm p hoc oete (rO"lnpt'rJliwlyl • Pelvic kiJnt·y Icnn~t'TlitJ1) • Renal transplant.

51

Re

'toneol masses

These usually ONUTt' the flSIliIS muscle on the affected side OT show a displaced fat lim' convex and beyond the mSOd~ muscle. They may show displarcment of tht' kidneys (see Fig. 2.Hl Of aorta. ,lfi' oft...n maligna nt, e.g. Iymph,ldenop.lthy, and n,!uin' furt her investigation. Do not mistake slight cunn-xily of the normally stratght pso;.liIS m,ITgins for pathology. These can hYP'-'rtmrhy in \"l'ry athletic individuals, just like the gastrocnt'mius muscles. Such Individuals lTh1y also shuw incipient degenerative cha nges in the hips in early adult life and medial deviation of the uren-rs on an IVU - signs to seek in confirmation, Look at lFig. 2,K):

•

eJgt' on the ll'ft sideand (lmWl

•

Theabsence(,f the normally ptlsitltlllN tll.1SS more lateral tn it Normal spit...·n

•

Upward and lateral displacement of thl' left kidnl' y,

fN>.h

This is TI'lwper1h>lwallymphadt>n0l'alhy, JUl' to lvmphoma.

52

r

Retroperifoneal mo sses cot1tittUed

Fig, 2,8- This is on lVU Mm showing renal excrejonina young man who presented with a moss in the neck, weight lossond backache.

53

Acute pancreatitis There art' no plai n film signs that co nfi rm or ex clu de ac u te pancreatitis. The d ia~ nusis is a clinic al one supported by high seru m amylase levels. Ches t and abdominal films will, however, usua lly hJ W been taken on admission wh ile the dia gnosis is being sorted out. Il1ldging th is condition and its complications is a jo b for ultrasound or CT, but underlying causes and seconda ry ef fects molY occdsilln,l lly be tderuified. l ook for:

•

Call-tone, Imay Ot' a pn..Ji!'posing fdctllr)

•

Calcification in the pancw,ls (chronic p.1l1cmltilis nMy be cumpllcated lIy MUT",nt bouts of acute pancreatitis ). Occasfonally ,1 tumour cont.lining calcificanon moly precipitate pancreat itis Pleural dfusiun s, b.1~1 dtt'lt'l:t,lSis, diaphragmatic elevation

• • •

Sign s of secondary Ileus R,m'ly in severe dtsease gas bubbles lll,l Y apf"t'a r in the panrn.'ols as abscess formation supt-'rv ent'S

•

Retnrperitoneal /;
• •

Ascitic tluid Bone infarct s t' .g. head of fem ur (w ry rare ).

54

-

Cater 3

Hollow organs The stomach

• • •

Abnormallv l.u ge stze (If the gastric outline Exce- sfve q u,l1ltity of st'mj o.:l i~l~ lt-d fpod in the stomach Smallqua ntitv of ~dS in the ..mall bowel.

Look at ( fi~. 12 ):

• Thetwo fluid le\'t'ls, that on the left representing the g.l.,tric fundu.. and Iholt lin the right the d uoden um - the so-called 'dou ble-bubble sign'. • Theactual levelot obstruction b in the duodenum, C,lU....-d by scdrring and ~It'm~is

frum ulcer di ....·,lSl;·.

Causes of gastric outflowobstruction •

Pepuc ulcer J

in dis tal "tomarh /duudt,t1um with scarring • Ca stnccam noma in antru m iSt',lSt'

• Lymphoma • •

Gastritis Crohn's diSl.'dSt' (stomach or d uod enum )

•

TIl

• •

lmpacted fllrt.·ign bodle, Bt.>ZOdT Ifurball, wgl·tahlt' m,llh'r)

•

~l t·ld SI.l ses .

55

The stomac h confj,,,...J

Calcified lymph nodes

Extensive semi-digested load e nd gos in the stomach Iilling ml,lch of the abdomen

Fig. 3. I -A 5J-yeor-<Jld mon with 0 2.year history of dyspepsia wha presen,ed with l,Ipper abdominaldis/emion, 0 succussion splosh ond vomiting. This wos due to outflow obs/ruction ond retention of food residue and Ruid. A 'bezoar' looks similar - re'oinedvegetable maffer (phytobezoar), or hair in the stomach (trichobezoaror hoirball, morecommon in animals) . 56

I

The stomach eorohr,,-I Mo5S

of

food

in stomach

Duodenal bulb

Gastric fundus

Fluid level

Fig. 3.2- Same patient: erectview.

Gastric neoplasms Sometimes tumours m,ly be visible in the fundus of the stomach un abdominal films and chest X-rays, this bein~ an (II:C<1SiOn,11 presentation of ~dslri( carcinoma . Such an ,lpf'l'dr,mCI' must, however, be interpreted with gIVolI (dUlion,,l'" a ph~"'ii\ll~ically contracted stomach canlook \ 'I'ry simila r, the left lobe of a normal

liver canindent the stomach here, and posroperanvely fundophcanun prOCNUrl'S prlldlK't' fill ing detects ml.J.iallythai sim ulate abnormal masses.In the appropria te clinical seumg hwight loss, anaemia. dy!>pt'p.;,idl, hO\\'l'WT, pollients ca using corcem 0\'('( this ,1ppe,U,lnet> should bot- inn...tigalt'l.l .

57

Distended small bowel Small bowel pathology usua lly manifes ts itself on plain X-rays by abnormal accumulatio ns of gas a nd fluid, due to either functional (i.e. ileus) or truly mechanical obstruction. The main problem lies initially in trying to differentiate sma ll bowel frnrn large bowel. Once the sma ll bowl'! starts to dilate the sma ll irrt>gular pockets of g,h that may be seen nor mally increase ,1IId coalesce, so that eventually the interior of the distended loops becomes com pletely outlined in continuity where the lumen is not occu pied by fluid and com plete mucosal folds appt'ar. Remembe r: • • •

• •

•

The colon is peripheral and containsfaeces and gas The small bow el is central an d contains fluid and gas TIle more d istal the obstruction, tilt' mort' loops you will SCI' TIll' longer the du ration of the obstruction, the bigger the fluid levels Fluid levels can only be seen on erect or decubitus films, and small fluid levels can occur nor mally It is not lleH'Ss,l ry to be obstructed to have fluid lewis.

The stan dard series of films in the acute situation is a minimu m of ,1 supine abdo men and an erect chest X-r,ly. Exper ienced radiologists claim to make do with these dione, but most mortals art' reass ured by an erect abdomen ,1S well. NB Th e entire abdome n shou ld be vis ualized, idea lly on both th e supine and erect film s but certainly on the supine film s from the top of the diap hrag m to the hernial orifices in the groi ns, as these may be the site of an obs truct ion in an inguinal hern ia. But rememb er that the pre sence of a hernia doe s not prov e it is causing an ob struction. Two fil ms may be requi red in each position to show the entire abdomen. Look at (Fig. 3.3):

•

• •

The multip le centrally placed loops of bowel distend ed with gas The outlines of folds crossing the entire lumen in places The absence of ,lny flu id lewis.

[ 58

Distended sma ll bowe l conh"ued DiSlended loops of small bowel

Stomach

Fig. 3.3 - Thisis the supine abdominal radiograph 0/ a patient presenting w ith abdominal pain, distension, nausea and vomiting_Note absence 0/ fluidlevels.

59

Distended small bowel conlin..-J GoslJic flu id level

I

Small bowel fluid level

Fig. 3..4 _ This is thesome patient in the erect position. Nore new thepresence of fluid levels. 60

Diste nded small bowe l eOll,illu«l Thi~ (HI-':. 3.4) is tht' d,lssic appt'Mance of a sma ll bowel obstruction. The rrlativelv small number of IllI'f'S indicates a mid small bowel rather than .1 distal

"lI1.l11 bowel obstruction. The cause was adhesions from prev ious surgt'ry so me ~"t'.ars

before. In order 10 demonstrate fluid levels you need fluid, llwrly ing g,lS and a horizontal beam erect or decubitus film. Withoul the g,b you won't see lht' fluid! Although oosuucuon and pertoratton usually pTl'St'nt S\'p.udtt'lyand clinically JlIil'T\'ntly, alwayscheck til make sun' the patient has not sustained a pt.'rforation as a complication of an obstruction. This is ,1 ra n - but import.mt even t. SB The differential dcgnosts of small bowel obstructio n includes poualytic dftl, and it may be hard to differentiate between the two un r,ldinlogical grounds. ThI.'c1inical context is usually crucially helpful, ('.g. immediatelv postl1pl' r,l!iwly. Re member: Hoth gener.llizl'd and Incalilt'd ileus molY occur, t'_g theletter \lith 'sentinel loops' ad~1Cl'nl to an appt'lldh .I1:'sn'Ss. ~B

Cause, of small bowe l obsuucuon • • • • •

Pustopt'l"<1livt' adhesions (up ItlllO'; of cases in western countries) lreernal strangula tion of bowel Iband or internal hernial htl'm,ll hernia re.g. inguinill) Lymphoma Crohn's disease

•

lntrnluminaltumuur

• Gallslone ileus (set' p,l/l;e 041 • InlussuSCl'plilm - usu.llly t"hildn'n; in .ldulb ofte n as!>l.JC1dlt'd with a tumou r. Tends tl' begin in theileum • Congt'nit,ll arresias - newborns. Lpdate: RI'O.'ntly spiral cr scanning of the abdomen hils ..hown itself 1,1 be a \'ery elegant way of dl'll1tllJ"tratin~ peritonea! ad hesions causing obstruction, but tilt' actual cause of 010.. 1"mall bowel obstructions is notap pa re nt from plain films alone. Confound ing factor: An inflamed or obstructed colon m,ly contain fluid, in addition 10 the pr t'Sl'nn' of small bowel fluid levels. Diffprl'n tiatin~ loops of ~m.tll bowel frurn large bowel can then be eXn'rtionally difficult.

61

Distended smell bowel conhn\.Oed A b it

of epidemio logy

As bas already been stated, in the developed world, most small bowl'! intt'St:inaI obstruction is CdUSl"IJ by adhesions. In place, such as Africa, however, ~ are by far the mosllikrly cause, as n>latiwly lillie in the way of pn>\iu\ls sUIKny "ill haw been earned out to CdUSt;' adhesions.

Voscular cotcsn opbee A mesenteric artery thrombos is or embolism is ,I cnticalevent pn'Sl'n ting as an ac ute abd om en . R,IJ iolo gk aUy the signs ,m.' those of ileus in the bowel. moving Oil 10 Infarction and pt""sibly gas formation in its walls. The clinical sentng, e.g. atrial fibrillation, previous myoca rdia l infarct ion etc., is im po rtant in suspecting this dtagnosts. Occdsion dlly mesentenc vein rhrornbosts "ill be the underlying cause as~lCidted with pancreatic carcinoma

Ileus Combined small and Large bowel dilatation molY form the eta ....sic radiologica1 signs of paralytic ileus which, as stated. may be hard to differentiate from obstrucnon.

Causes •

Postoperativ e - after h.mdhng of the gu t

• • •

Hypokalecnua Drugs, e.g, L-dOP.l lnrra-ebdommal <;l'r-is(pe ritonitis)

•

Bowel tntarcnon

• •

Trauma Reflex ileus from acute abdomen Irenal colic. Il;'.lkingaorta).

62

Di stended small bowe l conr',,""'" Gallstone ileus (0 specio l lor m 01obstruction)

Ihiscondltion b !\.'U~nilrd by ,lbnnllll.lllydistended gut and gas in an abnormal location, i .e. th e bili,uy tract . It b in f,Kt a misnomer, bt'ing due to ge nuine mechankal inte, tin.ll obstruction, CdW~>J by a 1.I1):;t' galbtlmt' impdcting in tht, ~t, u~ually at the terminal ileum wht'lV the bowel is rldmw.·""l. This occurs u~ually after fj~luld formation t.... twee n tht' gallbladder and the duodenum. It b QD('of tJw CdU~ uf intt">tilldl obstruction wht'!\.· the actual CdU~> lTldy be infl"fl'l'\i. l'nJLI!VIl.1Sl'd dnd untl\.'dl.>J it earn..... d high mortality Lonk fUT iRg. 35 ): \ lultlplt' dildll>J luop!> of ~1T\J1l bowel. i.e. o.'ntrdlly placed loops where tht' folds go right ~ I"'" lumen. Tht' colon l\"Il\oIilb normal. This indical~ '>U'IaO btlY..l'I t~tructiun . • The number til di..tended ItJl'p": the more there are, the more di~tdl the •

•

""""""""

.

Ga..~ in thebiliary tn..•. In thi... p..llil'llt tht't'I1til\' bill'duct i"OlItliooJand diloltt'\!.

Gob is ~I in the lumen tM tht'

~1IhL1dd("l".

However, largt'

~..able

qwntitit">of ga~ "ill notalwa)"s lit' rn_nt dnd onl)" in about a third otcase,

will the bile duct be lully di~p1.Jyl'd _ • The gdll..tore. Ml commonly thi .. i.. nol seen. but mAy be located in thtright iliac fO"Sd or uver tht' sacrum. It fn.qut'ntly consists of radiolucent ~erol "ith onl)' a thin cakifed rim , ITldking it hard to see, but in around til panents II ts ,"h.ihlt'. M tt~ t l*""tructing stones are over I inch 125 em) in diarJlt'tt"l", and may in fact be Iargl'l" than tht'y Iool if moll.' choIt">tt'fOl ha~ bt'\'!I dl'pt""itt'd bt-yond the cdkirwJ rim. If th.- p.!tit'fll was pmiou.Jy known to havehad a gdll~ttme in the gallbladder, look to see if it has ~ont' hum thdt jccenon.

' B\"0 ~tOl\t' was

\'i~ibll'

in Ihi~ pdtil-nl.

UU'>I'S of ga~ in th e biliary tree •

Pl't'\itJU~

•

lnstrumen tation, t'_g_"Rep / "phinCh'fillllmy

biliary SU~t'l")·. e.g. Whipple's operation or anastomoses III rhe gut

• Fistula forrrunon, t'.g. ~ll~ltlm' ileu-, • Posterior f"..rfl.ratilm lli In ulc•-r • Mali,l:n.lOt ~rll,',IJ to th.' bile du..t • EmphY"t'Tll.llllU" chn lt"'Y~liti~ (diJblotic-.1 • IAl\ sphincter (rhy~il>lo~ir,llJ. 63

Distended sma ll bowel con,inued Gas outlining gall b10dder

Gas in bile duct

Solid faeces in colon

Dilated small bowel

Fig. 3.5 _ GallsloM ileus This is a supine AP abdominal X-ray of a 55·yeor<JIcJ woman with a history af right upperquadrant pain, who now presents with more severe pain, fever, nauseaand vomiting. The X-ray shows distended smallbowel and gasin the bile ducts. You ca n also see gas in thegallbladder.

Distended large bowel Figures lb and 3.7 show a dbl'l ll'l rge bowel obstruction caused by a carci noma of the descending colon in an elderly woman who presented late w ith rectal bkoNing, weight loss and, Idtll'r1y, increasin g swelling of th e a bdomen. Colonic obs truction can ,1SSUrnt' a nu mber of ,1 ppt'Jrdnces, depending on the position of the obstruction and whether or notthe ikocacc al valve is competent. If it is.the caecum, being the mos t distensible part of the l,u KI' bowel, will distend, but if notthl' bark-pressure ....;11 be transmitted th rough the valv e into the small

00...1'1. and that too will distend, as in

it

small bowel obs truc tio n, but wi thout

caecal distl'IlSion. Dtsenslon of bo th of these pa rts of the bowel together can of cou rse occur withoul obstruction, owing to ill'us, and Isolated co lonic diste nsion ('colonic p5l!lldl>"Obstruction') may also occur assodated wtth medical conditions such ol~ Ml(myocard ial infarrtitlll). and thl' rad iologist may be as ked to exclude organic obstrucuon by run ning in some contras t medium retrog radely Th e critical diameter f(lrthecaecum is 9 em. beyond w hich it is in greet da nger of perforation. Look for: •

DiI,lIt'<J loops (>ocm)

• MJrked distension of th e caecum • Gmeral pt'riphl'ral position of bowl'! •

Several incom ple te ha ustra l folds, typ tcal of the colon, and a few complete ont'S- normal variation!

• Fluid faeces (III the Il'ft (erect film>, indicating colonic malfunction • Involvement dow n to the level of the descending colon • Alack ofdistensionof the small rowel, indic ating d competent Ileocaecal valve. 1\B Most colonic obstructions in the UK art.' caused by tumours (u p to

but in rau-e.

SOIllI'

f{I ~,),

other countries torsion of the bowel (volvulus) is the commonest

65

Distended large bowel COtl"nwd

Very distended caecum

Distended low lying Iransverse coloo

Fig. 3.6 -SupineAPlilm of abdomen. Female potienlaged 72, presenting with severe abdominaldistension. Nate the absence of Ruid levels. 66

Disjended large bowel «J(lhnued

LOfge fluid level in oKending colon Fig. 3.7 - Same potient ~howjng big Fluid levels in theerectposition.

67

Distended large bow e l conhn.-/ Cause s of large bowel obs tru ctio n •

Carcinomas (unlike the small bowel. where adhesions art:'the most common cause)

• •

Diverticular disease Volvulus - most commonly sigmoid and caecum (see below! in parts of the bowel with a long mesentery Inflammatory bowel disease te.g. Crohn'st

•

• • •

Appcndb abscess Metas tases Lymphoma Pelvic masses.

•

Ca uses of colonic pse u do-obs truc tto n (mdY require contrast study to exclude tru e obstruction and intervention to decompress caecum) Ml (with pulmonary oedema)

• • •

Pneumonia Mvxoedema.

Abdom inal hernia s Apart from being an intl'resting incidental finding, the prt'St'ncl' of external hernias is important because thl'y m,ly be the site of intestinal obstruction. From the diagnostic radiological po int of view the most sig n ificant application of this knowledge lit'Sin ensuring that when a patient presents with intes tinal obstruction the inguinal and femoral regions arc clearly demonstrated on the films - prt'fe r,lbly ill both the erect and the supine positions. If an obese patient has a strangulated hern ia in the region of the groin this may be d good way to help confirm it. NB Th e p resence of a hern ia in the context o f intestina l obstru ction dol'S not p rove that th e he rnia is the cause of th e obst ruct ion. However, if th ere is di rection al con tinu ity of a loop of bowel straigh t toward s a cu t-off segment of gut in a hernia, for example, tru e cause an d effect are most likely, Rem ember, if a h erni ated loop o f b owel does not con tain gas it will not be vis ible.

6'

Abd ominal hernias eonl,nued Scrotal hernias Appearance of hernias in th e groin

look for:

• Loops o( gas-fillt>d bowel e\tl'nding below the level Ilf the inguinalhgaments on both sides • Cuntinuityof I hl~ loops ",vith another loop in the true pelvis

• Enlargement of the scrotum 10 accommodate these loops (auscultation of the scrotum may render bow l'! sounds audible).

Fig. 3.8 - Scrotal hernias in 0 5Q.yoor-old monoThe X-fOY shows bilo'eral hernia foI"mo,iOll in !he groin, extending inta!he scrotum. This was on incidental finding and mepollem was nolobs/fue,ed 01 the lime.

69

Abdominal he rn io~ con'i"...d ulok
The massiw scrotum containing mu ltip le f,a../ liqu id levels Longitudinal fluid It'wls, indicating that Ihis is a decubuus film lpatil"nllying on his right videl,

Cause, of massive scrotal t'f\largtm\t'f\t are rare. Filariasis i.. one, but hemiatjon of bowel is another. It is Ihis sort of f,1'l,l'<S p.lthollOgy that gin'S rb t' to the old medical jokes about patients having tu ca rry their sc rotums a rou nd in a wheelba rrow! 00 not forget: • • •

70

A Richt er's hernia m,ly til' causing ,1 sev en-obstruction ,1t till' inguinallevel wi th only a sm,l l! p artial knuckle of b owel Inside it. Hennas can occur in ot he r locations, e.g. ,II and a rou nd the umbilicus. and co ntai n small and /of 1,Irgl' bowel, Internal hernias can also occu r - fOf instance into the lesser sac.

Abdominal hernias "'''h'n
I Fluid sunk to right

Gas risen to left

Fig. 3.9 -Apo'ient with a huge scrotal hernia. NBThis isa decubitus Film with tilepatient lying on his rightsideandlarge Fluid levels present with the gos/ying uppermost. 71

Consti

tion

Look for (Fig. 3.10): •

•

• •

The characteristic appearance of inspissa ted faecal matter - rounded masses of mottled or granular texture - due to tiny pockets of gas which they always contain. Find these and you've found the colon. La rger quantities of surrounding gas, with occasional haustral folds crossing part of the lumen and outward-billowing folds primarily in the periphery of the abdomen. The transverse colon may, however, be very tortuous and dip down towards the pelvis as it d ot's here. Formed faeces in the right side of the colon. This usually indicates constipation, as the material here is usually fluid. mobile and amorphous. Distension and loading of the rec tum and sigmoid (no t in th is patient). BUI these too Gill he grossly dis tended in severe constipation. In some individuals the colon may be distended 10 t ruly enormous proportions e.g. institutionalized patients who a re relatively asymptomatic but who pelSI' considerable anxiety when first x-reycd.

Causes of constipation • • • • • • • • • • • •

72

Painful conditions - aMI fissure, haemorrhoids Social -, irregular work patterns, hospitalization, travel (\ong f1ighls) Psychological - institutionalized individuals/defectives, depression Elderly - immobility, poor diet, altered routines Colonic disease - carcinoma. slow transit, excessively long colon Postoperative - childbirth, pelvic floor repair Paraplegia - autonomic dysfunction Drugs - analgesics, opiates, antidepressants, iron Parkinsonism - retardation Hypot hyroid disease - generalized reduction in bodily functions Chagas' disease - trypanosomiasis infection with megacolon Hirschsprung's disease, in children. In this condition look for huge mottled masses and gas in the surrounding periphery of the colon.

Ccnstipcuc n conlinued

Fig. 3.10 - Constipation This is a 55.year<J1d woman who presen,ed with increasing obdominal poin. distension, and camp/aiMs of reduced bowel Irequency Youcan seefoecol overloading in /he Jorge bowel.

73

The a

ix

Appendicitis is the most common acute surgical t'm t'f);t'IlC)o', but most appendices an' nut visible 011 abdominal X'fay.;. Often the dtagnose, and treatment are straightforward. but occol.;ion.dly difficu It or atypical pn'Sl'nt.ltions occur and under the,e ctrcumstaoce, abdominal films nwy he helpful. First check that ,my woman of reproductive dgt' b not p~nant. as appe ndioti.. oncn (l('(UI"S in lht' ~'Ol.mg, i.e. ask about the UtP: your patient molY have dysml'llIlrrhlll·a. ~B A norm al X-n y d oe s not exclude app end iciti s and no one rad iological s ign confirms it. How ever, wh en certa in radiol ogical signs occu r together in th e appropriate clini cal setting, the likelihood of appendicitis being th e correct dia gnosis grea tly Incre ase s.

A word about path ology Appt'Tldkitis is caused b~' blockage of the mouth uf tfus o~an with inspi~led faece, or a calcified rna..s lhl'n'ol Ifaeoolithl, k',lding 10 dish'R"ion and infection, .;umlllnding inflammatory reacnon, bowel sta ..i..and potential rupture - reflected over lime from t'll>rmality to t'SlJ.bli...bed rad iolog ical changes. Thi... mg. 3.1) is appt'nJicitis complicall'd ~. d~S tormanon. Look for:

•

•

Calcined f,1l'r olith.s. ThI'Sl'ffidyucrur ill normal f't"l'I'It'bu t alsooccur in Mou nd H 'l of p.1til'nts wit h acute appendicitis, and .I.; Ihl' y grow mdY t,l ~t' on .I laminated apJ'l',u,l I1CI'. Theyare different fmm calri fk d lymph nod ,....A duster (If four faecnllth s is I'n"it'nl here. M,I"S euec t around the appendix. The b!.IWI'lllIOPS are displaced alliolY h-om the pri mary focus of infection d ue to oedema , ruptu re end abscess formation, with walling (lff by the gll",ltt'r omentum - 'the abdominal J'l.lict·ffioln' .

•

74

De-tended loop!' (Ii bowel - 'sentinelloops'. The-e are du e 10 localizl'll ileus from the inflamma tion or matting wit h ad hesions, going lin ttl complete mtesnnal obstruction. It is the adjacent colon that is distended here.

The a ppendix COtlIiIl.-J

Fig. 3," - Localiied view of erect film of a potiellt with abdominal poin commencing centrally and then localizing to the right iliac fossa, followed by increasing toxicity, fever and a palpable moss in the lower rightabdomen and tenderness PI? on the right, 75

The appendix COftlinlJe<1 An other appendicilis

This (Fig. 3.12) b the l\lWt'r right quadrant detail from the film ot a 6O-yt'.u -01J febrile patient with initial central abdominal pain . 1,ltl'r localizing to thl' lower righ t. Look .11: The curved C -sha ped ut>jo:ct in the right flank The black density of its interior.

•

•

This is g,lS in the lumen of an inflamed and tUl);id ,'ppt'ndix. It ts it rar e sign and must be interpret ed w ith cJ ution, .ls it TThly .l lStI occur in normal peopl e. Other r.1dil,logic.t1 signs tu took for in appendidtis include:

• • • •

Free &-1"> - a wry serious stgn of perforati on - either intra ",,'ritoneally or in the I1'tTllpt'rihllll'lIm (the ,1rpt'ndix canlie in either S!"'lCt'l, but this is ra re. u'J>,,, llf the right pso,a.. margin, but again this is ,l non-specific sign. Flexion or sl."o1iosis concave to the affected side. This ls natures WJy of relieving sp.lsm in the muscles on the pa inful stdc. It ma y also be seen in trauma or n'JIJI colic, but doesnot always occu r. Otber indirec t signs of inflammatinnyintra-abdormnal p"thotugy l"ausing h_s of clarity to thl' right properitnneal fat stript' in thl' [lank, Much is often made of this sign . But: This art',l shllu ld be included on abdominal films bu t often il is not , You will uftl'n need it tlrighllight to see it, bul often it is too dark 10see ,l nyw.ly even when the relevant a rea is included.

• •

O ther radiolog ical man ifeslatian s of the append ix

•

Remember that the appt'ndh may retain barium Imm a l'\'n'nt enl'md or oral barium study for m,lny weeks or months. Failure to fill docs not nl'Cl'S.;arily ind icatl'Jl<.t'a "l'; abo, most patients are nil-by-mouth a" emergencies, tht'reby pll;'("ludinll oral barium .l~ a test. although wen it to till up with contrast that would rule out appendicitis ,1S thecause, thu s requ iring alternative p.1 tholo~y to be so ul';ht.

Point of interes t: Colonic diverticula may retain bari um for man y weeks or months afil'r a barium enema or meal, cau sing possibl y dozens of \"t'ry den se

76

The appendix con~"ued

I

Fig. 3./2 - Finding of gas in the lumen of the oppendix (arrows).

Opdahl...around thl' (Ilion. If you can !>l'l' what looks like this, jook in the nutl",ur X-ray pach'l for the rutpnt.

Remember- RI'I,linl.,j barium from r,ldiologicillstudies is a rare but n'O~nill.,j cau-e nf arpt'ndiritis, Footnote: Non-mvasive rn'i.lf'l'ratiw imaging ilSSl-"'Sment for 'lpf'l'nJicilis may nnw N' sought by ultrasound and CT, looking for an appcndicohth, a distended ,lpf'l'ndi\ >6 mm in di,mll'll'r, and surrounding intlammatnrv signs of oedema or fluid.

77

Volvulu s Volvulus Of 'twbtin);' can atfcct ,11ly pMI of the intra-abdominal g,lslwinteslinal tract , including the stomach and small bowel, but Ihb is relat ively rare. Mort>common, but slill Tl'l .ltiwly ran.. compared with allother ca uses of obstruction of the larg e bowel, is volvulus of the sigmoid colo n ,md the caecu m in western cou ntri es, although ittendv 10he mort' frequent in Africa, for example.

Sig moi d volvulus Thi s (Fig. 3.131 usuall y occurs in ddt'rly p.1til'nts who have redundant loops tli si ~m oi d colon on ,1 long mesentery and ,1 history of constipation. Subacute rnamfcstations or vague symptoms molY occur bu t in the acu te form the pat ien t m,l y become !*'wTl'ly ill with abdominal pain , complete consupation an d , on I'R, an empt y rectum . Dela y in diagnosis ma y lead to ischaemia, gangrene. perfora tion and death. Look for:

•

•

•

Agrosslydislt'ndl'd loop of sigmoid colon cxlt'nding from the pelvis to under the diaphragm. Compression tll);l'ther of the two medial wall s p roduces the 'coffee bea n sign' , Erect films m,ly show exce....»ve quantities of gas rela tive to flu id > 2:1. A lack I,f haus tra. These a n- df,'cc-d by thl' enormous dislt'nsi on, bu t other loops of colon underlying it nMy simulate haustra in the distmdt-d loop . AJX''t above till' lthh vertebra in the !hIlT,10C spine, aga in a measure of the S!'\"{'rity of distension that occurs in a true' volvulus. This point is off the top of this film, which was only one l,f severalneeded to demonstrate the enure abdomen and chest.

•

Convergence Ilf lower margins of the distended loops on the h'ft.

•

UWT overlap ~ign - indicanve I,j the J l'gTl.,,(' Clj distension of the bowel. i.c. a colonic ICll.1p to the height (If Iht' liver OT above it on the right.

•

wit flank overlap sij?;Il- indica tive of d istension of the same, i.e. tht'ld t limb llf the 'coff\"\' bean' owrlil"i the dl'Sl.'l'nd ing colon, which m,ly b- seen behind

•

'Free air' - sign of perforation tnot present here y(1 ).

it.

Thl.... e are tht, d .lssic signs uf a s igmoid volvulus, but in so mt' pat ients tho radfological signs ,1Tl' atypical and therefore Il"Ss obvious. Rc-tw gr,ld l' running-in of con trast med ium pl'T rec tu m may show a twisted bea k-like or 'bird of p rey' sign ,11the poin t of con verge nce III the distended loopsand confirm the d iagO(~is.

78

Volvulus

cont'nlJfPd

Painl af coeicct

of two medial

walls

Gra551y

dilated

Point 01 convergence

sigmoid

fig 3. 13 - SvpineAP radiograph , Sigmoid volvvlus_Anelderly instltutionolized woman aged 76 with on ccc te exacerbotion of long·stonding intermittent abdominal symptoms of pain and dis tension, and prior constipation. Note the distended sigmoid. This is the fomovs 'coffee bean' sign.

79

VoIVlJIU5 <;()(l~n.-l

This conditi on m,ly respond initially to endoscopic tuba l manipulat ion and decompre.stoe, but mos t will Tl'CU C. Defmifive su rgt"ry with pa rtial colonic resection may then be required. Pe rfor ation and gangre ne co nsti tu te an acute l' ml'rgency and requir e immediate su rgical mtevention .

Inflammatory bowel disea se It is not th e rob of plain film rad io log y to es tablish the diagnosis Ilf mild mllammatory bowel disease, which requires tissue biopsy, but rath er to evaluate patien ts presenti ng with exacerbations or complications then ot, a nd ot ber than in obstruction it plays little part in the assessment Ilf smell b owel disease, tor which barium studies are required. The normal c olon. however, usually contains semifluid faecal mailer on the rig ht-han d sid e and more sohd faecal ma tter on the left-hand slde . In suspected inflammatory large bowel disease therefore look for:

An absen ce of forme d faecal mau e r in the left-h an d s ide o f th e colon. This ind ica tes that the colon is not carryi ng out its functio n properly, i .e. storing its contents for a su fficiently long time and absorbing water from them , and these p.1tients will usually haw a history tlf diarrhoea. Diarrhoea of course has m.my causes (st'l' nppos itl'l, includ ing gast n rintestinal tract infl'Ctinns and the use of apenents e.g. in the preparation of p atients for r,ldiological procedures. At times this can ill' so marked .1S to produce a virtually faeces-free and 'gaslcs s' abd omen. The patient's history - e.g. of recent fOll'ign travel , self-medlranon or the medica l use of supposltoncs etc. - there fore becomes p.lTamllunl.

'0

Infla mmato ry bow el di sease C()(l~nvN

CaufoeS of diarrhoea Th~ are conveniently divided into acute a nd chronic.

Acult • • •

Inft'\1ion~, t'.g. gastroenteritis, food JXliwning Dit'lary excesses: lager and hot curries! Iravelters diarrhoea due to E.roIi, £"lam,lrM, ShigrlLJ etc.

\'oIt': 'The 'gesless' abdomen, where the X·ray shows a lack of faecal matter and ,dlT1O'>t tlltal absence of gas. may indkate earlv obctruction, diarrhoea or 1.lytiw use.

Chronic • • • • •

•

Inflammatory bowel disease Kmhn 's, ulce rative colitis) ~lJlabso.lrption

Infection (p.-arasitt"S) ~lJlij;n,lnry in bowel GI ~ul};t'ry (vagotomy, pa rtial bowel resec tion, blind loops etc.) Constipation (in the t'lul'rly) with 'overflow diarr hoea' and rectal plug

•

LIX,I!iVl.'S

•

Endocrine causes pancreatic insufficiency pancrea tic neoplasm thyn'to"in~is

di'lbt'!ic autonomic neuropathy.

Complications of inflammatory bowel d isease

Small bowel Thi~ usually involves Crobn's diwa'o(" and plain films may show intestinal oboolructilln or sij;n~ of fistula fonn.llion leading, for t'\ampJt'.lo air in the urinary eact (hl.lddt·r, ureter. I"t"lUI pt"hisl or the bili'lry svstern ti.e. bill' duct). Rall'ly I1Idlign.mcy ma~' supt"' v ene.

81

Inflammat ory bowel d isease COIIMuod

Lorge bowel Louk fllr (Fi~. 11·1):

• •

The ~l'nl'ril lil l'li lack of formed faecal matter The oedernatuus folds of mUCIN , l'SJ'l'l'i,llly in the transverse colon .

This is called 'thumbprinting ' and is USUJll y

inflarnmanon in the C
of thumbprinting, till' more common ones including:

•

Crohn's Jist',lst'

•

lschacnuc colitis

•

Intramural haematoma

•

1\.1eI,1SI,lSl'5

• • •

Lymphoma Pseudomembranous cohns Allergic m lCtions ('culonic hi n ,,>'),

82

,1 manifl'Slationof

acute a nd st'WIl.'

ttl ulcerative colilb . Then- are, however, many

Inflammatory bowel disease conlinvod

fig. 3.14 -A43·yeor-okJmon with acu/e diarrhoea passing slime andbleeding perrecnen. This i5 a 5upine AP film showing on ocuteexacerbation of ukerotive

colitis.

83

Inflammatory bowel drsecse

con'.......d

This (Fig. 1 15) is a case of toxic nwgacolon (lr toxic dil.lIatiollof the colon . Look f(lr:

• •

Cencraltzcd or localized dilatation of the lumen of the bowel [» 6(01) Lobulated mil~!'ot's in the lumen (inlldmm<1tory P'*'udopolyps)

•

Excessive ga~

•

Absent faeces (note that the intraluminal masses art' ..mooth and contain no mottling due to pockets (If gas) Gas in the w.ll]llf the bowel (nnl present here. but may indicate imminent pertorationl Evidence of free gas - pneumoperitoneum - 'double wall stgn ' if the bowel has perforated . Not present here Evidence of gas in the portal vein. Not present here. when present this is usu ally an antemortem event.

• • •

Toxic di latation of the colon is an acute surgical eml'rgl'ncy and this patient required .111 ('ml'rgtmcy rohxtomy, wh ich was carried out forthwith.

84

Inflammatory bow el dtsecse ,on~n..ed

..

Fig. 3./5 - This is a 35·year.a/d man who wasodmitted in a sfale of shock with bloody diarrhoea. He hod 0 history of ulcerative colifis_

85

C a fer 4

Abnormal Gas •

•

• •

•

86

Gas i~ tnt' bud y's own natural contra st med ium and its appt'ardlKt' ,1.. tht' darkes t dt'nsity appt'.1Tinli on X-rolY films should now be familiM to you, espt'Ci,llly in the abdomen as wella-, in the chest. M(~I t.f the time it is confined to thelumen of the gut , w here ynu ra n ma ke great U"C of it to deduct' the diameter, and mu cOSJI Sl..l tl' of the bow l'! wall. HIW.'I'\'t'T, the problem is: (iI) Ih,1I111l' gut is usually undergoing peristalsis (If varying degrees , solh,11 (h ) enormously va riable qu antities l.f g.tS may Pt.' prt~'nt from p.llit·nt to p.1lil'nl and from time 10 tim e, both (If which l,u th t' observer ttl lTV and interpret comxtly. Dilen only ,'arts of tht, bowel an' visible. (c) adheren t faecal residue may simulate mucosa l abnormality in t1w colon, as may residual food in the stomac h. Much les s fn'quently. but most importan tly from the d iagnosti c viewpoint, owing to a variety (If "'ltholl ~kal PTIJCt'!O~"S gas m,ly l"S('ape fro m the lumen of the gu t into the peritoneal cavity, as wellas into the retroperitonea l SP.lO". More subtly. it may track into the w,l ll of the howe] ilst'lf and , by fictula format ion . fu rther break into other sys tl'ms such ,1S the urinary Of biliary tracts, Of even out ont o the surface of tlw skin tcnrerocutaneo us fislul.l ). Gas nMy also track down into the abdomen hum the chest, form in abscesse, as a result of infection with ~ps- rroduri ng organisms, ,1ppt.',U ill vessels such as the port.r l win ,IS a preterminal even t, and alsoappear ,I S ,1 result of i,ltmgl'nic activities suc h as em bolizeuon procedures re.g. in the kidn l'y ). It mo st be undt'~llll>d that extrelumnul intraperitoneal gas is to No expected after surgl'ry, laparoscopy or pt'fitonl'o11 dialysis, so that the radiolugist must be given thl' relevan t clinical inforrn.rtiou and nol Ix> misled intu di,lgnosing pathtlll~Y incorrectly as ,1result of failure by the chntoan to provi de it.

Abnormal gas •

con~fliJf!d

Conversely after ,In iatrogenic procedure such as endoscopy extraluminal g,IS should not be expected, and its prl'st'l1n~ in tha t situation indicates a catastrophe, i.e. perfo ratio n of the gut. Th e pro cedu re need not have been technically d ifficul t for thi s to o.. . cur.

Pneumoperitoneum

1

The radiological signs of a pneumoperitoneum are among the most important signsin radiology, indeed in medicine. Somettmes the amoun t of free g,lS is sma ll and you may have to work to demonstrate it. Miss it and the patient may die . t ook for: •

• • •

Bilateral da rk crescents of g,lS under both bcmtdaphragms. NB Figure 4.1 was taken erect, so the gas has risen . This is a large p neumoperitoneum , but small amounts of gas require time to rise to the subdia phragmatic position so it is a good idea to leave the patient upright for 10 minu tes toallow this to happen before taking the X-ray Gas may appt'ar on one side of the abdomen only, usually the right No gas may be seen if the perforation has been scaled off by the omentum If only a small amount of g,lS is present it may be missed unless the film is centred at the level of the diaphragms - usu,llly a chest is centred around the fourth thoracic ver tebra. With at tention to de tail as little as 1m! of free gas may be demons trated.

87

Pneumoper itoneum

COfllinved

Fig. 4. I - B.L Erect CMsl film. 6O-yeor<J/dpalient with0 hislory oF uker disease, presenling with acule abdominal pain and boarcJ.Iike rigidity in the abdomen. Note the bilateral radiolucen' collections of gas under each hemidiophragm. This was due 10a perforated duodenal ulcer. There isalso a moss in the left lung.

88

Pneumoperi toneum

«>nlin..-i

Supint'films will usually have been taken mutint>ly with tbe erectones.and certain JnOl\'subtlesignsof free-gas in the peritoneal cavity have been described to enable thediagnosis to be established under these orrumstaeces. LOllk for. 11Ie double-wall' sign (Fig. 4.2), i.e. bot h stdes of the wall of loops (If bowel become visible because of air on t il l' inside and air on the ou tside - try to find an isola ted viscus surh as IhL' stomach Of bow el loop, but remember that c1O!'ol'ly apposed loo ps m,ly give J false positive 'double-wall' sign • ' Football or d ome sign'. With a l,u ge pneu moperitoneu m the und ers urface of lht'di.lphragm may be-surround ed by air,giving a darkdome-like apP'-'drdnct' in the uPJX'fabdomen even on supine films • visualization of falciform ligament - 'Si!Vl;'T'S sign' t Cas in Ilk' scrotum in children • Inseriouslyill patients theu~ of erect films may not be possibleand decubitus films with the left side down centred on the right u ppt>r flank should be taken.

•

Bri!\ht lights m<1 Ybe rcqc tred to St't ' this art'a propt'rly, as for technical reasons thl' films often come out very dark in this situa tion .

89

Pneumoperitoneum

con ~nued

Gas at falciform ligament

80_ sides seen he..

- Only 000

side

01 colon wa ll ~"

here

4.2 _ Pneumoperitonevm- 'double-woll' s;gn. This isa wpine abdomenshowing some of the more subtle signs ofa pneumoperitoneum.

90

Pneumoperitoneum COIl~JW
Thl' CJ IlSt'S of a pneurnoperiton eurn art' legion and are oft.. . n divided into those with clmealstgns (If peritonitis t be exe rcised in dealing wit h patients on luger doses of steroi ds. These dru gs both pr edispose th e pat lentto ero sion and perforation of the uppe r GI tract and then mask the sy mptoms and signs. Th e diagnosis of perforation then relies entirely on the X. ray, so iI h igh ind ex o f suspicion for th is phe nomenon mu st be main tain ed. Nott' (Fig. 4.2): • •

The diaphragms an- not visible, nur ,my gas beneath them Free gas , however, is dclini lt'l}' present as both the inside and outside wa lls of parts of lilt' colon art' visible , i.e. the ' dou ble-w all' sign

•

CoilS

is tracking up the fakiformligament.

Causes of a pneumoperitoneum With pni toni tis

• Perforated peptic ulcer (stomach or duodenum ! • Intes tinal obstructi on • •

• •

Ruptu red d iverticula r disease r l·llt.'trating in jury - gu nshots, knife-wounds etc. Ruptured inflammatory bowel di~'aS(' te.g. mt'gat'o lon) Colome mfections (typ hoid ).

Withou t peritonitis

• •

rvst ldpamtomy

•

Jejunal divertirulosi..

•

Steroids

•

Trdcking from cht...t Ipneumothorcx)

r(~ldpa~lpy

•

Pentoneal dia l ~is

•

Vagina l insufflation (d ouching, squatting, oral sex , postpart um exercises .

water-skiing) •

Pneumatosis coli.

91

Differential diagnosis of a pneumoperitoneum M,my im portant phenomen a can sim ulate a pneumo periton eum and lead 10 mi..Jiagnosis a nd unnl'\.~ ...H )' surgt.'Ty, wit h all its medica l and medico-legal com plications. A good selection of these is shown to emphasize their crucial importance.

Linear cteleocso (Fig 4 .3) •

Linear att.'lrt1.lsis is a phenomenon that occurs in the lungs, usu.llly at the

00_ . •

It is frequ entlv olSSll(i.lll'd with infectum or pulmonar y emb olism and is com monly seen afll'r anaesthet ics in the posh'f'l'r,ltive st,lt,'. II form s ..1"11"" horizontalor curved bands which m.1Ysimulate the diaphra gm. • Noll;' how the band atthe righ t costoph rentc anglt' curv es up mstead of down. Norrreny it resolves within days or Wl"t.'k..., hu t may persist for [llngl'r. :-.iolt.' (Fig_ 4.4,

•

•

92

r-':I4l:

11k'band of iocn-ased dt.'nsity running just dhow the med ial p.trt of the ri~hl hen udiapbragm, CTt'ating a Iccent view lIf the air in the lung beneath it and simulating a pneumoperitoneum. This is a more subll.. e ...ample of linear atelectasis following anaesthesia. Nolhi ng had ht...·n done 10 the abd omen.

Differential diagnosis of a pneumoperitoneum rorolillued

Fig . 4.3 - This is a case ofbiloleral/;near ole/eclas;s simulating 0 pneumoperilaneum.

93

Differentiol d iognosis of 0 pne umoperitoneum continved

Bond of linear atelectasis

Fig. 4 4 - This is a postopero,ive generol anaesthetic pa,ienl who has iust had ENTsurgery Detail from figh, boseof a chest X-ray_

Chilo iditi's syndrome - colo nic interposition

Note (Fig. 4.5): • • • •

The inciden tal find ing of pockets of gas beneath the right hemidiaphragm Multiple bands {If mucosal folds indicating gu t. This is colonic interposition. An abdominal film ShOWNcontinuity with the rest ot the colon Rarely the sma ll bowel may interpose as well This Oldy lx· intermittent in nature, i.e. presen t on one occasion and gOHl' the next.

It may Pt.' seen with shrunken livers (cirrhosis), in COPO with a large thoracic

9'

Differential diognosis of

0

pneumoperitoneum conrin..-d

fig. 4.5 -Chiloidiri'J syndrome Colonic interposition. This is the chestX-roy of a 60-year-old male with chronic lung disease.

outlet, ro~llll'l'rn l
95

Differential d iagno sis o f a pne umoperitoneum ronli"ued Meteorism

Look for lFig. 4.6): ExC\"Ssi\'E' air swallo v..ing ott en associated with crying. espeoauy in children, ca usi ng gut distended with gas to cro w d up underneath both hemidiaphragms. tlnterposmonagam lID the nght.I Folds of the bo w el crossing the ga.... filled lumen, confirming the pn.'Sl'Jln' of

•

•

gut •

Superimposition of bowelloops Co ntinuity (If loops wi th oth ers in the abdomen.

•

This is meteorism. Thl'rl' were no abd ominal symptoms and nu perfora tion .

Subp hre nic cbsce ss (see Fig. -4 .15 )

•

Fluid levels under eithe r benudaphragrn. more commonly the right.

This usuallv occu rs postoperatively in a wry !>id.. pdtil'flt. Part (If the gds .....ill ntten han> been gl'nl'ratt'd by organi-om!> and will nut all hi> residua l from the lapdmtnmy. Ultrasound may be wry help ful in dl'mll nstrati nf; fluid, but w iIl tend to hi> bloc ked by .my f;as that is present. CT may then be required . PL.J in Xr,lys, ho w ever, etten frrst alert on e to the d i ,l~n lls is .

96

Differential diognosis of

° pneumoperitoneum I;",,'inue
Fig, 4,6 - Childwilh meoleorism This isrile X-rayofa yovng child w ith a suspected chesl infection who hadbeencrying profusely beFore the Film was token.

97

Rarer problems cau sing a simula ted pneumoperitoneum • • •

Skin fnlds, especially in the elderly, infants and severely dehydrated patients Cortical rib margins overlapping diaphragms Lobulated diaphragm with gut underneath one or more humps.

This is a matter for careful inspection and analysis of the films. NB When there is doubt about a preumopcrttoncum or demonstrating the site of a leak is required. ora l water-soluble contrast (but not barium) can be given to try and demonstrate a perforation, unde r screening control by a radiologist. Barium should not be used as it is harmful and dangerous should it escape through a perforation into the peritoneal cavity, exact-rooting infection and causing barium granulomata. NB Just occasionally one Of other of these phenomena can coexist with a genuine pneumoperitoneu m. Dual patho logy is by no means unheard of. Fal beneath the diaphragm Look fur (Fig.4.7): • • •

Constant radiolucent stripe beneath the left hemidiaphragm Constancy in the size, shape and position over time and no movement with change of position, e.g. a decubitus film Associated cardiophremc fat pad at the apt-'x of the heart.

This is a hpoperitoneum, i.e. a collection of fat beneath the left hemidiaphragm. Note its similarity to a genuine pneumoperitoneum. A hpoperitoneum is more likely to Of cur in an (I~ patient or one with a cardiophrenic fat pad indicating tendency to form excess body fat. The lucent lint' however is not quite so dark as gas giving an important due to the diagnosis.

98

Rarer problems

lucent stripe allot simulating

0

conhn.-/

pneumoperitoneum

Fig. 4] - Deloil From one of a number of idenhcal chesl X-fOYS taken on !his patienl over several yeors.

Distended golslric fund us This can form a n e ... ten stv e quant ity o f a ir a p pa re nt ly beneath th e left hrmiJia phragm. Look for. • • •

A fluid level in the l'rt'ct position. as st.'l'n on most norma l chest x -rays Typical disposition of the stomach in continuity with gastric funduson supine film The totalthickness of theleft hemidiaphragm. A 'na ked' dia phragm with fret' au-on either stde of it measu res only 2- 3 mm . With the thickness of the gastric fundal wall beneath it the total thick ness will approximate to mort' like 45 mm in total. Proceed with caut ion, how eve r. as excepn ons can (llUJr.

99

Ga s in the retroperitoneum On occasion gdS molY collect in the ret rope ritoneal sp.lce and cause a so-called p neumoretrope rnoneum . However, il is u~ually d ue to rupture of parts of the gut

with retroper itoneal cornponentv, e.g . the d uoden um o r rect um. either sfll.lntJ.Ill.'l.lusly due 10pathology or following instrumentation. such as t'Tldosropy. or pt.'tll'traling injury te.g. a stab wound). At ,lnl' nme the deliberate introduction of gJ.s inlo the retroperitoneum Wo1'> earned out a..a diagnostic procedure. by in>ot.·rtinl; a needle Ihrough the perineum and injl'cting carbon dioxide - 'presacral pneumography" - 10 demonst rate renal or adrenal masses, hut this is now completely obsolete. Neverthel.....s Ihis iI1u..tranon of the technique ..how.. well what to expect and what you will see

when it occurs. Not('; • •

•

The intt'n'ot' black o.1t'nsity sumlUno.1 ing the rstMS muscle margins, the kidnt'Y'" adl\'nJb and spleen M,lr" t'l.1 t·nldTgt'mt'n t nf the right adrenal and spleen Ass("lci,lIt'd gas in the pe riton eal cavily, which nldY or mdY not (,IS ht'rl') bt'

pre- ent. NH C,l" in the rctroperitoncum is a >ot.'rinus r,}J iological sig n ,100.1 n-qu in'!l urg" nt ,l....>ot....cment to find it.. CdU~', ,llthough the preceding his tory i.. u!'>u,}lIy obv ious. :\8 A lack of gas u nder e ither he mid iaph ragm on erect films does not exclud e a perforatio n, ,10 0.1 air in the retro peritoneu m will nol necessari ly be .a...socia ted wit h .Iir u nde r e ithe r hemidiaphr .agm . A pecte riorly perforating ulcer m.ay lead to .air only in the re troperito neum. l n I1I11 SSi i ' t pe rforations free gas m.lYreadiljbe wen under bo th he midiaphr .llgm .... even o n SUI, int films. Ofil'n, however, retroperitoneal gas is pre-ent only in small quantities .mJ ('\Ii'l.. tilutt~ d subtle radiological finding. But do not mistake streaks (If dirt in tilt' erector spillal muscles fllr I\'!rnpt-"Iitol1t.'al gdS in the t'lderly.

100

Gas in the retroperitoneum c~ Right

odrenol

Very dar];

retrcpe rhonec l

go,

Spleen

I

Fig. 4,8 - Retroperitoneal gos - old X-roy From a deliberofe case of 'presacral pnuemogrophy'. Notethe intense 'negative contrast' highlighting 01thekidneys. Nate also the enlarged spJeen and big right adrenalgland. 10 1

Postoperative abdominal X-r

s

There ,11\' so me important facts worth emrha~izingabout these films . FTt'!' gas in the abdomen is oOTITlilI after sU'l;ery and usually diminishes d ol r b)' dol)" on the early supine films. If the amount of gas does not diminish it may indicate the breakdown of an anastomosis or It'aJ..agl· from the site of recent surgery. After several days , when the patit>nt is feeling better and sat up, the gas n-es. and it may then appt'ar that a lot mort" of it is suddenl y present underneath the diaphragms when previous supine or semlrecumbent films art" compared with erect ones. Remember this phenomenon and monitor it Mort" misdiagnosing a 1t'alo: . The patient's clinical state will be d go..ld guide.

Tips: •

Take advantage of any view of the lung bases you get on abdominal films. The amou nt of energy required to demonstrate the abd omen is much greater than for a chest X-ray, and lung bases that 'ca nnot be shown ' due to obes ity or poor inspi ration on co nven tional Chl~1 x -rays may show u p pa rticula rly well on abdominal films - for basal atl'lt'Cl.lSis, effusion s, cavities, meta stases

etc. •

• •

•

102

Askin g for 'an upper abdominal film" m.1Y be a sub tle WilY of gettin g the r,ld iogrilpht'r to show the lung bases for you. On pos toperative films look particu larl y d ost'ly for signs of left lower lobe and linear colla pse. Colo nic uue rposition mily also occu r postoperatively Do not forget to loo k ext remely cri tica lly at the position of all tu bes. d rains, stents and coils that may haw been p ut into the abdomen and maintain a high ind t'll of suspicion for sigQS of inft'd ion, ileus, etc. Remembe r ea rly post-ope ra tive films may ha ve 10 be do ne on mo bile machines and be technically 1t>S.... Sdtisfactory and mort" pront' to artefacts .

Gas in the bilior tree This has alread y been touche d on un der ga lls tonl' ileus. Re me mber, t he

gallbladder and bill' duct are not routinely li,ible on pla in X-rays and, when illustrated in texts. haw usually been injected wit h contrast mediu m so that Ihey show up while . It is im portant, however, to leam to idt'ntify familiar anatomical structures prese nting in a n unfam iliar W,l y, that is, wh en outlined by gas. Th is is known as ' negative contras t' . The clinica l stall' of the patient will be a g(lod guid e as to the potential seriousness of finding gas on X·ray in the biliilry tree, e.g. very sick with gasforming org anism in fect ion , or clinicall y well d ue to p rev ious choledoc hoduodenostomy surgl'ry. In the p
anastomosed to the gu t to fill them with COl a nd monitor their subsequent size - a form of 'coca-colagram'; thereby avoidi ng the risks of iodin ated contrast. UllJd".mnd would now be used, howev er, and can de tect gils by brigh t echoes coming from the bile d ucts.

Gas in the wa ll af the gallbladder Asopposed to !}IS in its lumen, g,15 can occu r in the wa ll of the gallbladder itselfso-called 'emphysematou s cholecystitis'> d ue to infection wi th gas-forming organbms, especially in d iabetics. It look... similar to gas in the wa ll of the uri nary bladder (Sl'l' Fig. 4.12). Other Ih,111 those slated on page 63, causes tlf gas in the biliary tree includ t>: • • •

Crohn's dtseese

Pancreantis r.uasi tt'S, l'.g. ascmasts .

103

Gas in the urinar tract As with gas in the biliary tract, the findi ng of gas in the urinary tract usually indica tes recent instrumentation or else something serious ~oin~ on, such as ~as­ forming infection or fistul a forma tion. Causes of gas in blad d er lumen (see X-ray nn p. 182)

•

latmgemc, e.g.cystoscopy

•

Out' to fistula form.mon.

Causes of bladd er fistu la • • •

Malignancy of bowel, bladder, genital system Cro hn's disease Diverticular disease

•

Po stoperativ ely (controlled trauma'}

•

Trauma (uncontrolled}

• •

Radiotherap y Foreign body

•

Ulcerativecolitis.

Note (Fig_ 4.9); • • •

104

The distension of both collecting systems from the obstructing effect of the bladder carcinoma The white outline of the left renal collecting system by contrast medium - the usual 'pos itive con trast' from the i.v injection The blac k ou tline of the right renal collecting system, i.e. ' negative contrast' from intrapelvic and intracakycal gas on this side, plus the non -fu nction of the righ t kidn ey.

Ga s in the urinary trcct COIl,ill.-l

Fig. 4:9 - Gas in thecollecting system. This is the Film of on IVU sequence From a pahenl with 0 corcinomo of the blodder who, in addition to hoematurio, complained of possing 'Foam', with bubbles in his urine. A Fistula hod formed with the bowel, ollowing gos/o enler the bladder ond the rightureter,

105

Intramural gas H,wing assimilated the norton of gas as the body's natu ral contrast agl'nl for the purposes of diagnusis within the bowel. and evidence of the wry serious situation of t"SCape and leakage from it. it is now nl'«'S..y.ry to recognize and understand the significance of gas in the W illi of certain stru ctu res, where it may {l('('asionaUy be found Isee below) , e-g- the bladder, Intramural gas may appt'ar virtually anywhere of course, but in practice a c ommonly important place to look for it is the colon, I'.g. in chil dren.

N ecrotizing enteroc o litis

Look for (Fig. 4.10): •

• •

Intramu ral colonic gas, especially on the right-hand side - note the d,uk margins forming a connnuous track A normal appearing loop of bowel in the left flank with a normal wall of softtissue d ensity contras ting with gas in the lorren Cardiac leads. Moniilm ng of the child n>t1t'C1s the severity of its condition. The child has also been intubated tnote the endotracheal tube).

There are many causes of intramural gas, a list of which is given after several mon' examples (page 11 0).

106

Intramural go ~ conlin.-J

lnlromurol_

9"

Fig, 4.10 - A young infant presenting wi,h prostration and bloodydiarrhoea. Note the veryclearedge ofthecoJon outlmed bygos in the wollof thebowel. This iJ necrotizing enterocolitiJ.

107

Intramu ral g as

con'i"UfId

Pneumatosis coli Look for (Fig , -1.111: •

Ga"C)'.,ts pmtruJing inlo the lumen of the 1aJ};t' bowel causing a mulliplidty

small pockets, far in t'1la'SS of normal in the right uPJ't'l' quad rant Di..tornon of tnt' normal mucosal pattern Evidence o f perfora tion (not present here! - this may be locallzed or gt'neralized, i.e. a pneu moperi toneum. or track i n~ into the mesentery. The-e 'pop pmgs' of the /;<1S cysts a n- us ually benign but present wi th rec u rrent bouts of abdomina l pain. IIf

• •

Tht'rl' nl.1Y be an dss.xi,ltl'U colitis in these patien ts an d l>ccasiunally a p-ychiatric hist(lry.

Mulhpfe gas cysts

Fig, 4. " - A54.year-<J/d woman with fecurren/abdominal poinond diarrhoea, This ispneumafosis coli.

108

Intramural gas

COI1hnued

Gas in the bladd er wall ~(ltr (Fig_

• • •

-tI2l;

pod,t't~ overlvmg the arc of tilt' bladder outline This is '("ffiphy!>t'md tou ~ cystitis', d"~OCi.ltloJ with gas-forming urgani..ms in 11K- wall of the bldddl'f A large rectal plug ..urrounded by gds ca n look similar, so caretul dnalysis is f\l'('('Ssary but the got.. mdrgin i.. usuallv srnt)l.lth.

The multiple irrt>gulaT lucent

I Fig, 4.12 - This is thelower abdominal X-f0Y of a 50-year-old man w ith severe IIrinory trod infection. The pohent was diabehc.

109

Causes of inr,.cmurcl gas

Common •

•

Inf lammatory bowel duea..... -mily be a ~i~nof impend ing f'l'rfuralion in toxic dilJ.tJ.tion of the colon, J.complication of ulcerative colite, lschaermaof the bowel causing incipient nt."OllSis/infJ.rction, JUl' to. strangulation

volvulus

•

necrotizing ffitt'rncolitis obstruction [premature infants) l'neumatusis CYSlllidl"S. Usually benign. Onen ,In inddl"Ilt,l l finding on X-ray (p. l Oll).

Rare • •

•

Diabetes with infected gut wall (J.ISll g,lllblilddl'r and urina ry bl.lddl'r) Iatrog enic (post l'flJOI'CUpy, biopsy surgery) Obstrucnve pulmonary disease tradun~ down from chest (.l~lhl1ldtics, CDI'D patit'nt5)

•

Pt'plic ulcer diSl"dSt'

•

Peneeranng injury

•

Steeolds tmav be stlenn.

110

Intra-abdominal infection Approach to the problem A vt ry high indt t of susp irio n must always lit' maintained for the ~~ibility of intra-abdominal infection, especially in pt ..... toperanve patients who do nut recover quickly aner surgl'TY. This is also true for patienls who all.' ju!>t vaguely unwell but pyrt',ial on admission, as well .IS tho!>t.· with localizing signs. Common major ronce ms are the subphrenic abscess after su rgl'fY, and pericolic abscess formation from rupture (If the ap pendix or an infected colonic divertirulurn, although these will usually N' accompa nied by pain. Penetrating injrries are also a potent SOUTCl' of transfer of ba cteria into the a bdomen (knives, bullets etr.I, causing peritonitis. Abscess formation lead s to pus, and a l.ugl' liquid collection m,ly be readtly detected by ultrasound (If CT but remain only as a vague mass dl'nsity Of even undiagnosableon plain films. In the presenceot gas-forming organisms, however, tither multiple small bubbles Ofabnormal larger collectionsof gas and fluid may mabk a plain film diagnosis of abscess formation to lit' suspected , and indeed thegas thus formed may block acoustic access and render the plain film superior to ultrasound for diagnosis in this regard, but no! CT. wteo en abscess is forming in a ca\ity the semisolid materia! milled with gas bubbll'S may give it a granula r texture like faeces, so caution must be exercised heft'.Agood clue to the prt'Sl'flce of an abscess is the constancy of its posjtl on , so 'look for the gas that has not moved' on serial films. Try to gl't vrcct Ofdecubitus films with the affected side uppermost, in addition to supine films. Normal gut undergoing peristalsis cau ses changes in configu ration minute by minute, although ileus may complicate the situation. Sentinel loops may
111

!

lnno-cbdominol infec tion continued

Fig. 4, /3 - This is thesupineAPfilm 01 a 72-yeor. old man admittedwith marked left /ower abdominal poin and renderneu. The patient was known to have e}(tensive diverticular diseo!e, most profuse in the sigmoid. This is on anterior abdominal wall abscess caused bytrocking oot to the left from on infectedruplured sigmoid diverticulum, which hoderodedinto the lower left overhonying {obesityJ anteriorabdominal wall. Look f~lr (Fig. 4.131: • •

•

The large left-sided circular lucent ,11\'a over the left hip, left iliac blade and left pelvic region . This is ga~ lying anteriorl y in it largl' abscess cavity The muttipledenseopeotie, in thcpelvts - this is rel:'lint'll barium in diverticula from ,1 p revious enema. indicating that the piltient has diverticula r disease, and indicating alikely cause for the current problem The large gas-liquid level over the left hip region on the second erect film (Fig. 4.14l. The weight of the fluid ,10.-1 g~'lll' ra l downward movemen t of stru ctu res in this position is typica l. II is too big. high a nd lateralto be euher it femora l or an ingui nal hernia . N~'l'llle aspiration con firmed pu~.

112

lmro-cbdominol infection

COIIhnueC

,

I Gos-liquid level

fig, 4 14- Lefllower anterior wall abscess (erect Filml ,

113

Intra-abdo minal infec tion Conhrl.-i N B Occas iunally an abscess may form within a sulid organ, (w ating a ga.. liquid level, e.g. in till' liver; spleen. and of ("(JUN' the brain . look at (Fig. ·t IS): •

The g,IScollectiun under the right herrudiaphragm

•

T he assodated fluidlevel...This is pus in the abscess, indicating mult iple locu li and an erect film The thi nn es.. of the right bemid iaph ragm, indicat ing t his b a 'na ked

• •

•

•

diarhr'lgm' The absence of .my mucosal folds , supporting tht' conclusion that this is not part of the gu t, i.e. colonic interposition, or interposed sma ll bow el, Elevation of th e right hermdiaphragm . This m,ly or m<1 Y nul be pr esent . 'Splinting' of the right hernldiaphragm m,ly alsu occur, i.e. pa ralysis on screenin g, but 'screening of d iaph r<1gm s' is now an ant iquat ed concept and does not rule ou t a subphrenic abscess. Evidence of an ,ISMIC'i,llt'J pleural effusion Of lobar collapse on rl u-same sillt', which m,ly or mol Y ntlt be prl'S('nt (not ht'rd .

Cu nfirmat ion and imagi ng gu idance fur drain age may be ea rned out under

ultrasound or cr control.

"'

lntrc-cbdcmincl infection conhn.-l

t~h, wbphreftic obscl!'u A 63· yeor-old woman who hod a choIecysledomy corried 011' 8 days before. who is now pyrexial ond tender in the righ, upper quodrant. This is a large righ~ sided subphrenic abscess.

Fig. 4 15 -

115

C a tar 5

Ascites The accumulation of free intra peritoneal fluid in the abdomen is an important clinical finding confirmed by the class!c clinical sign of 'shifling dullness', Rad tologtcally a sign of massive free fluid includes distension of the abd omen. In the supi ne position the bow el will tend to float on lOp of th is poo l of ascitic fluid and lake up a central position. Some separa tion of the loo ps themselves m,ly also ocrur b..X:ilUSI' of the accumulati on of fluid between them. Ab u look for:

•

A bulging shape to the abdomen

•

A dense central grl'y part and sharp cui-off Idll'rally, with dark flan ks, due 10 the mar ked distension and abrupt change in curvature-of the abdomen Greyness or 'g round-glass' apf'l'
•

•

• •

Causes of ascites •

• •

• •

Hypopr oteinaemia (loss from gu t or kid ney) Cirrhosis of liver Congestive hea rt failure Inflammation (panc reatitis, tuberculous nodes] Malignancy with per itoneal metastases

•

Lymphoma

•

Occlusion of inferior vena cava

116

Asc ites con~n.-J

Fig , $ .1 - Asciles Supine radiograph of a cirrhOh'C 48-year-old po,ienr with centrally ploced loops of small boweland a distended abdomen. Thi, is ascites.

• • •

M,lInulrition Nt'phwlic syndrome Constncnw pericarditis.

A' toaccurnulate in the pelvis.tracks up the paracolicguucrs. tlwn gr
Cater 6

Abnormal intra-abdominal calcification The causes of pathological calcification within the abdomen art' man y. Onl y the mort' common an d importan t ones encountered in everyday clinical radtojoglcat practice will be described.

Abnorma l vascular cclcilicc tion First remember that impo rtan t medical conditions such as diabetes and chronic Tl'I1
Aorta/aortic aneurysms If nCH's.<;ary. go back and revise the section on the normal aorta {PI' 24--25}. Gel into the habi t of IOllking for the aort a on l"'lwy abdominal film, young Of old . If neu'Ssary make it your 'favourite organ' (set' hints at end of book). Crucial fact: You mu st develop a very high ind ex of sus p icio n for abdo mina l aortic an eury sm b ecause th is con d ition is so dangerous yel so poten tially and emi nently tre atable by su rgery or stenling., and it is frequently pick ed up as an in cidental find in g on p lain abdom ina l X-rays. The pa tien t's life is then well and truly in the hands of those who see his films, and abdominalaortic ,1Ot'urysms haw repeatedly been missed on X·ray s in the past , these patients subsequently dying suddenly when they ruptured. If you learn not hin g else from th is book, learn to be ruthless in seek ing uut aortic aneu ysms!! Ten second s' search iog may save the pati ent's life. 118

Aor tic an eurysms continued

Fig. 6. 1 - Aortic aneurysm A 65·year-old diabe ric and lirelong smoker. Note

me large calcified moss bulging totile left. This is onabdominal aortic aneurysm. look for (Fig. 6.1):

•

•

The typicalthin line of calcification in the wall of the aorta. Most .1I1l'urysms bulge 10the It'fl, bu t occasionally thl'y may bulge to the right or symmetrically about the midline and stillhe entirely over the spine Associated calcification in tIll' iliac arteries, which is
Aortic oneurysms r;t;HIlinued C linical/ra d iolog ical problems •

•

TIll' physiciannr su rgeon may think he feclsan aortic anet l!)'5rn in thea bdomen a nd requests a n X-ra y ' to e xclud e it ' , Thi n pa tients, o r pati ents wi th except ionally lordotic spin es, mol Y we ll haw a very palpable or 'thrus ting' aor ta , ,lS may hy pertensives. so A nor ma l aerta m Ay s im ulate An Aneur ysm . An obese patient may have a big ant'u rysm which cannot be confidently palpated. although you may lit' able to fee l it when you know it is there!

NB In abilit y 10 palp ate an a nt'ury sm does no t mean th e pat ient has not got one. You should not be d igging 100 hard a nyway, in case yo u bursl .In undia gnosed aneurysm. •

•

Mos t aneurysms contain thin rims of calcification in their walls, but overlying gas. colonic man-rtal and X-ray scatter m,ly make them nory hard to find . The edge of the rim may lie just at the edge of tht' spine and be misinterpreted as part of the spin e. Someaortic aneurysms have insufficient caktttcatton in their walls to lw seen. but norma l anatom y may save the day.

Look fur: •

A normally calcified aort,l (p,ltit'nts ove r 40) ove r the sp intowith pa rallel or d(lf5 exclude an anvurysm. but both walls mu st lit' unequivocally identifi l.,j to doso. Be aware. how....vet, that not t"l'l'TY body's aorta calcifies - 1'\' t' O in theelderly.

converging Willis; this

Poin ts 10 po nder: I. Around oOIXl men die in tlw UK each p 'ar from ruptured abdominal ,lOI'UI)'sms, and some I.f them have aln',l dy had abd ominal X-rays taken . 2. Albert Einstein died of <'I ruptured abdominal aortic anl'Urysm ,

120

Aorlic aneurysms conlin..-l Oher more complex problems • •

•

The aorta lTIdy be tortuous or bent but not aneurysmal. an aTll'Ury!>m in an arM,. beoing defmed a!> loss of parallelism in its w alls . OnlYOlK'of the two w allsof a tortuous but parallel-walled aorta Illdy be visible - usually on the Idt. 1IIl.lking like an anWl)'!>m w hen one is not rn~'fll. A true aneurysm may haw one w all bulging to the right of the spine - get used to looking for it hen' as well.

•

Rarely some am'Ury!>m~ are so large kg. > 8 em) and their calcified walls so far apart and atvpfralthat they go undetected if the observer is unaware of this phenomenon, ur they may blend with the sac roiliac ~li nls tow er down.

• •

Musl ant.'Urysms an' asym ptomatic. Vt'!')' rarely the-superior rnesen tenc artery may caki fy and, taking a long curved CUUN 10 the Id l of the -pine. may simulate an aortic ant'UTysm . In this situation . ho w ever, the aorta itself is likely 10be ralo fied and should be visible asweD. look at (Fig. 6.2):

• •

The thin rim (If calofxanon 10 the left of Ll and distal to it The even more subtle rim of calcification to the right of 1..4 adjacent to the lumbar spine.

The patient had non ·op,lque ga llstones . This was the typical incide ntal radiological presentation of an abdominal aortic an t'urysm. or 'triple A'. It was missed by the first two doctors who k-..l"l>d ,1t lht' film. Look at (Fig. 6.]) : •

The unequivocal fO(,11 expansion of the calcified wall of the abdominal aorta, confirming the prl'Sl.'flCl' of an ant'urysm.

~B All ilTldg~ on X.ra ys are slightl y magnifit'l..! and thi.. tndude, olnl'Ul)'slmo, but aortas O\'!"T 3 em are usually ~nJt'\l .I .. allt.'Ury~lTIdl . SOITlt;' aortas can be » em in diameter [so-called 't'Ct.1tic'l, but Nt" Jnt'U.ry"1TId1. "0 Illtlk for departures from parallelism, i.e. l(lUl at the ..hare III the aorta.

121

Aortic

o neu ry~m~

contonued

Fig. 6,2 - This is the supine APradiograph o( a patienl X-rayed (or righl·sided abdominal pain. The firs t /WO doctors missed Ihe aneurysm.

122

Aortic aneurysms

conhntlfKi

Fig_ 6.3 - This is a lateral view of the some patient. The third cJoclor who sow /he previous Film was suspicious and requested this further view, confirming me diagnosis. 123

Aortic a neury sms cOII/iroved

What To 0 0 7 A~

in m ,tn y other situations the answer to the radlologfcal problem lies in

requesting further views. Do nul struggle on with just one film if you .H~ not sure what is glling on, but it is best practice to seek help before r..... irradiating the patient u nnecessarily. Ho wever, if you are alone and still unsure you may: 1. Req uest a lateral view of the abdomen. This will get the aorta off the spine and you will have a clearer mental pic ture of what you are looking ,H. 2. Req uest a su pine left posterior oblique view (" right anterior oblique view). Th is is often superior to the lateral an d givt'S an excellent dew of the aorta in isola tion from the spine, although yuu may find it harder to in ter pret. Radiologists, however; find this view extremely valuable. The solu tion to the possible pres ence of an ,lIleurysm may therefore be solvable with plain X-

rays, but ultr asou nd or abdominal CT are Ihe next investigations of choice. Is it leaking? An early decision must be ma~e with an acute abdomen as to whether to proceed stra ight to theatre or whether theft' is time to Image the ao rta, even with plain films, Are the rena l arteries involv ed ? [f the i1nt'urysm extends as high as L2 this is likely, but accessory renal arteries may be present at a lower level and can never be excluded by plain films. CT ,lIlgiography, magnetic resonance angiogr aphy or con venhonal angiography may be l1l'Cl~sa ry to confirm or exclude these. Look at (Fig. 6A): • • •

The irregular convex edges of calcification 10 the right of the lumbar spine The clea r righ t p~(las margin Loss of the left rSO,l~ ma rgin and increas ed soft-tissue density on the left side with a convex edge further out 10 the left.

Th is is a leak ing abdominal ao rtic aneurysm, with a haema toma accumula ting in the retm per iton eum on the left side. NB Clea r ps..lilS margins do not pnw e
' 24

Aortic aneurysms conl;n....d NB Calcified lymph node

;:o:;~.:-'T.,~, _ '\0.

..' (

•

~'...... ,

Fig. 6.4 - This is the abdominol X-ro y of 0 75-year-old woman odmi ffed with severe abdominal pain andbackoche, The patient wos in 0 stoteof shock with a rapid poise ond low bloodpressure. This is a leaking oortic oneurysm. rNB the hme 01 the lopof the film . This ;s the sign of a veryill patient}

125

Aortic aneurysms <:o<>,inl.'ed 7 leaking aortic aneuTysm tool for:

F""'-ld." muscle on one OT

•

A retroperitoneal rna....effect with oblilL'fdtiun uf the eithe r side Obhteration of one (IT (ltht'T OT both renal ouuroes Displacement of lidney.. Displacemen t of the aorta by the haema tom a lleu.. in the gut Lumba r scoliosis

•

The aortic ant'urysm concave to the side of the leak which it..d f ma y or mdY

•

• • •

•

nol be visible. Urgent ultraso und , or prd('r.lbly spiral CT, ..hIlUM be ca rried out if there is time , Non-urgent dnl"ury"m.. should still be seen quu..kly by a vascular "UTl!;l;'l.m for further advice, d~ding on their ..ize. TIlt' prublt'l1l has then moved bt>yon,j thl.' realm of plain films . Smallerall€'Ul}'sm" can be monitored t'wl')' Ii IllImth.... by

ultrasound .

Other an eurysms: iliac/splenic/ renal Although a hig h indt'''' of suspicion must be maintained for abdomina l aortic

,1Ot'urysms in ord er to lil' II'CI the m , JIll'urysm.. in othe r ve..-els may ,1150 {l(CilShm,ll1y be seen. Look for (Fig. n.5): •

A bico nvex calcified rna..:-distal to the left or right of the point uf division Ilf

the ao rta .II the inferior mdrgi n of l 4 •

Continuation of any aortic anl.'ury..m di."l.dly, a." here, into expanded iliac n"'-.I'ls . This l'" often 170'H IhI> case , but 111,>t always ',0, and an iliac
Reme mber- Although k..... common than abdominal aortic ,1Ill.'Ul')'''rru.. iliac art ..l')' dnt'Ul')'Sm... can kill ~'tlU if tht.-1· ruptun-. The didgllllSis is fl'ddil y con firmed with Doppler ullrdSllUnd if IOU much bowel gd" dot'S nul intervene, or by CTI CT dngingrJphy. They
126

Other aneurysms: iliac/splenic/renol continved

Fig. 6.5 - Huge Ieit iliac orrery aneurysm A 65-yeor·okJ mon X-rayec/ forabdominal.??in in whom en abdominal aortic aneurysm wos found bulging to tile right of the spine. Another calcified moss WCIS n01ed in /he left side 0/ /he pelvis. mis is on iliacartery onoory5ITI. 127

O ther aneurysms: iliac/s p le nic/re na l ~ontin.,..j Splenic arte ry a ne urysms

Look for (Fig. 6.fi) : •

Thl'ldt/right marker, It b very t'a~y when putting such films up III assume the patient h.l~ gallston'.... on the righI, wht'rL'.I'" these l,,,,,ions .HI' on th,' lett. ChIodo the l/ R marker on e\"l:'ry film ~'ou look at and Jon't put it up th"

""nmg w ay round •

•

One or more circular or incompletely circular calcified m.h~ in theleft upf't'r quad rant Splenicartt'r y colk ifk,ltion. This m,ly or molY not be present.

Spll'nie .u lery .lnt'urysms tend to N' discovered incidentallv nn lh" X-rays of cldl'Tly f'illit'Tlt!>, and are tju- second 1110st common kind of ant'urY~1ll found in theabdomen, with about two-thi rds contain ing rnkification. They molY also occu r in yllung women and han> a tendency to ruptu re durfng prl'gn.mcy, with a ditfl'll'ntial diagntl'>isof a 'ru ptu r edectopic' and a high Illllrtality. They <11-e usuallv asymptomatic and Idt alone in the l'ldl·rly, butthe opinion of ol va....-ular surgeon l1Ioly be sought. They mav also occur in portal hypertension .

Renal artery aneurysms These all." ran' and usually an incidental fmding on imaginJ;. but around uru- in five isbilateral. They m.1Y be .ls.... lCidl,'I.l with hyp-rtenston, pain and haernaturia, and must N' d iffl·n.'nliat,'I.l from renal calculi, g,lllstont.... etc. as tht'}' presl'nt ,1'" cakified rounded opacnte, in the l1.mks. Causes of anl'urysm s • • •

Artt'fio'-;CI,'rosis Hypertension Infec tion (mycolic)

• • • •

Trauma Congl'Ilital Fibromuscular d ysplasia Polvartentis nodosa .

\"8 Th.. plain film detection nfan ,lnt'urysm will USU<111y 11'.lU to urgent further 'higlH K h' inn.... li ~.ltio ns In con firm its pn"Sl'I1Ct' .1I1d extent, but the abse nce of a visible dnl'U I)"sm on plain fil ms docs not mean the pati ent has not ~ot one.

129

liver calcification Calcified lesions in the liver are relatively un common bu t occur from time to time. Of those that do, representative causes include: • • •

Old gr,m u]nmas (TB, h i~t{lpl,l s mosi s) Primary live r tumours > hepatoma Secondary liver tumours, e.g. colloid carcinomas from the collin, O\"lry or stomach Hyda tid cysts with fine lines or contracted 1'l.l gl'S if partially collapsed: the 'water hly' sign.

Calcified g a llbladder. ch ro nic c ho lecystitis

Occastonally the gallbladder itself may calci ty - ' porcela in g,lllbladdl'r' - or the hill' within it maybe (If high density - 'timey bill"

-c

both these rht'0I1mt'M being

associated wuh chronic cbolccysnns.

Fig. 6.7 - A 59-year-oldpotientwith /ine stippledcaki fication in the liver. This

was secondary tIImour froma colloid carcinoma of the colon. Note the ossocio/ed elevation of me right hemidiophragm due to liverenlargement.

130

Splenic cakmcation Calcification in lht' spleen is an OC'C<1"'inn,,1 and usually Incidental finding on abdominal X-r,l}''''. It mol Y \'dry from oneor two specks of calcification to lal');t'r ma",~

occupyinl'; almost Jl1 of the

.. n uself.

~plt,

Cau<,('s • • •

Cysts tcnngenital, pe-t-traumatic, h~ddtid) Cranulorru (old TB) Phlebolith» (h.ll'm.ln~iom. l)

• • •

Infarction r.u asilt'S(Anllilli.frr an/lil/alu,,) Sickle rell anaemia.

Fig 6.8- A 50-year-old woman. Incidental finding ofcalcified mass in spleen. This was a benign cyst bul note ,he big liver.

131

Calculi Renal calculi (Fig . 6.9) The majority of stones (1:l5--9()%) that form inthe kidney s are radio-opaque, owing to their calcium content . They ma y ran~e in appeilrann' from multiple tiny opacities (nep hrocalcinosis) to one bi)'; opaque stone comp letely filling the collecting system (staghom calculus). The plain film problem consbts of proving that an opacity mai ntains a constant position in relatirm to one or other kidney by oblique films, erect films or control tomography, and diffcrennating between punctate costal cartilage calcification and g
Hype rparathyroid ism Infection SI,lSis /obstmction Dehydration Hypervita minos is 0 ~1edullary sponge kidn ey Schistosomiasis Gout (uric acid stnlll'Sl.

132

Calculi

conlin"""

Fig. 6.9 - AbdominalX· ray. S/oghorn coku/us on leftside. The righl one;s as yel incompletely formed. Th,ue can be treoteel by shod·wove lithotripsy and percutaneous e.trodion methods of interventionol radiology.

133

Calculi conri"ued

Fig. 6. 10- Nepftrocokinosisin righ,/CiJney The left kidney hod been removed.

134

Ureteric cokuli •

•

In p.llit'nb who prc-ent with suspected renal coltc the hunt is on 10find the obstructing calculus. R.1n'ly other 11'Si!l11s, SUChdS a sloughed p..lpill'l or bloodd ul may cause obstructive sym ptom'>, but first and foremost ynu a re !I}()king fora small calcified llpdrity in the hne of the ureter, Cynics will tell you that ,111 you can SdYabout the ureter is th,1I 'il goes fmm till.' kidney to the btaddrr", LI'. it may he tOftUOUS, dilated and Pl.topk (and Ihb i.. truel, but the usual cour....• is out of tht' kidney, up onto till' F",0.1S muscle, along theline of till' tips of thetransverse pmu'S,*'Splus Of minus a few nulhmcrrcs, down over the pelvic brim and SI ~lin ts, round parallel to Iht'lateral aspect of the true pelvis, then mloJia l1y into the bladder above the level of the Ischial spmes.

Crucial fact: If you see such an opacity in a symptomatic patient do not a..sum e it is an obstructing calculus, as many phenomena can mimic such a stone, e.g. costal cartilages, calcified lymph nodes , pelvic phleboliths etc. You must then request excretion urography (if the patient is not a lll'~ic to ro ntri\st mediu m] (al for the r'ldiologist to pm\'{' whether or not the OpJcltyis an obstructing ageut. (bl toconftrm thelev el and constancyof Ihl' obstruction by serial films, and (e) to c onnrrn whl'thl'r or not the obstruction is complete. The level will then dictate the management and approach to intervention, shoultl this be required. Remember. Emergency IVUs can teke many hours to complete if tht' kidney is severely obstructed, because (If delay ed excret ion . The exami nation is nor complete until the level of the obstruction is established. Thereare three main positions where ureteric stones art.' especially likely tu

ol>«truct:

• Thepelvturctenc junction • The pelvic brim • The ureterovesical junction. What about allergic patien ts? Renal ultra....umd may show a dilated collt'Cting system, and an ultrasound (If the bladder may show J 'ureteric jet' of urine from the affected side, thus excluding obstruction of th,lt ureter. Control IT scans of the abdomen may show oedema typical of an obstructed kidney and a calculus in the lov..-cr end of the ureter on the sameside, thus avoiding contrast medium. 135

Ureteric calculi con~nuM M eg~ hi n l: Ii shm..m an [VU film in an exam always ask til SI;'t' the control film: this is. d film of the abdomen taken ~'fnl\' any contrast medium i~ ~i\'l'Tl. This will:

(a) Ensure that you do not miss an of'dqUI' calculus , which may 'disar f't'ar' completely after contrast is given teven a complete sreghorn calculus), eo you will not see it (see Figs 6.13 and fI.).I);

fig. 6. , I - A 46-yeor<>/d man with left renolcolic. Nole!he /'wo opocitoes in!he 'eft side of !he /rue pelvis. ?colculi.

136

Ureteric calculi conh'"ued (b) Impres s the examiner and conH'Y the fact that you understand IVU exilminations and ju,,1 t'llilctly what you art' trying 10 do . Even if you art' not shown a control film you w iII be giVt"fl credit for asking

for it :'\8 A trainee rddiologisl in a radiology exam might be failt'd for nvt obking to _ a control film, .;0 this is a most important concept.

Fig, 6.12 - Same patientafter canlrasl, Nate /hehydronephrasis and dilatedleft the opacities, confirming tha' these were obstructing

ureter down to the /evel of

cakuli. J37

Ureteric calculi I;o"'i,,ved Value of control film s.

Fig. 6. '3 - 3O-minufe poJkonlrostfVU h"lm Jhowing opparenl large right Jroghom calculus ond normally excreling left kidney.

138

Ureteric calculi conli"...d

lytic

0000 lesion

Fig. 6. 14 - Control film onsame patient beFore contrast, showing only a smaller obstructing calculus at the right pelviureleric junc/ion and cakareOtJs debris in the inFeriorcoly}(. Note also the lytic lesion in the left iliac bone. Th ispotien/ had disseminated meresratic disease andhypercalcaemia, predisposing 10 renal slone formalion .

• •

TI\l.' interpretation (If a post-contrast film Tn.1Y l>t. \'l.'ry different after its control film is seen. Bealertto the unexpected incidental finding and look right rou nd the film for lither abnormalities . 139

Bladder calculi Stones in the bladder an- relatively rare. They can N' either larg" and solitary t'.Ioi. the sill' of " hen's egg, nr sma ller, multiple a nd faceted. They may ilPp l'.Jr fortuitously in patit'nts betng x-reved for other purposes. or be found in the bladder in patients btoing sp'-'<:ificall~' inn·stig,1tl'l.l for urinary tr,l'l problems (d ysu ria, hacrnaturia etc.I, Look for:

• • • • •

140

A calcified object lying in thl' midlinl'. In thl' supine ptl!'ilio n with a It.1 tlf urine in the bladder a heavily calcified stone will move tu the dependent position, i.e. the postenur concavity of the hl,lddl'r. Mobility. [f you rl'l1ut-st right and [l,ft decubitus films mobili ty ttl the righ t and left dependent p-lSitions in a full bladder within its molJ'giTls "ill confirm J bladder calculus (an ultrasou nd l'll.,lmin,1liun would, hOln'wr, be preferable 10 "void Unnt'H"S",uy r" d i,lt ion). Remem ber that a r hnmtcallv Inflamed bladder may be contracted rou nd a stone .1nJ the patient unable 10 achieve bladder filling , precluding demonstration (If th is phenomenon. A blad der stone mJy ,KtuJlly be in ,1 bladder diverticulu m and therefore both eccentric from the midli ne and immobile on decubitus films . Further irn.Jging lt'Sts would be nl'Ct'SSdry 10 confum this (IVU, ultrasou nd . CT 11c.). Occastonally a pelvic kidney can con tain slonl's a nd fUIII you in to misdiagnosing 'bladder stones'.

Bladder calculi con ~nlHHi

Fig. 6. 15- Bladder calculi. This patienl hod hoematuria anddysuria

141

Ureteric/bladder calcification Somethi ng to be dls nng uis hed fro m lum ina l calcu li in these st ructures is calcification in the walls of the u reters and /or bladd er. This is a n' ldliwly rare phenomenon in UK patients wit h causes such dS pos tradia tion cystitis or neoplasms, but a \ .t>ry important dnJ commoner radiologicdl finJin~ in certain other coontrt ..... where schi...to..,umidsis is endemic . Bladd er calcification require, 10 be differentiated from calcified fibmid.., occupying its ptlSitw'\n and prostatic cdlcif!caliun in It, base,

•

Nt't'plasms

•

Pos tr sdano n

• • •

Tubl'rrolosis 5chistrl'.om iasis Amyluidnsis.

142

r

Ureteric/bladder ca lcifica tion COIl~n.-l

Fig. 6./6 - CakjfieJ risht urelff A case 01 right·sided tvbercvlous aulonephrecromy with calcification which has progressed down the right ureter. Nole olso the old left psoos abscess/roding down to the lefthipjoint, which has been enteredandbeen parliallydesrroyed bytuberculous disease from Ihe spine. This 0150 gave rise to a 'cold' abscess in theleft 9,oin. The disease on theright was arres,eel before il reached thebladderwhich didnotcalcify.

'4'

-

Prostatic calcificotion I'ca lculi'J •

•

In men dgN 50 and over films {If the abdomen and pelvis may b...-gin to show pu nd.l l ~· I'p,ui lit", ,l r~'!l'dring N'h ind an d above the sym physis pu bis. caused by calciflcnton in the pW!!.I<1II'. This l1lJ.y be a...",Jctillt-d with infection, but thi.. to. ntlt usuallv thl' [.1"'1' , It IndY be fint' (>I' coarse and ocrupy only part1>1' allnf the gland , "'II is nul d reliable predictor Ili prust,'lk size. 1'nl'.t.llk (,llctfic,lliun is Mt pn-,(ilnn'wus in il~.'lf. but it dlll.~ nllt exclude m,dignolncy in anoth..r part Ilf thl;' gland. ThO' main differentia l I!> from d urethral ca lru lu.., which is u..uallv midlillt." in f'O"ilion. uniformly den-e. ..mooth and ....lI1ldry Do not mistake the en-face soft-tb..ue ..hadow III Ilkpeni.. for a cdkifil'\i bladder shmt', rn~t.ltl' OTureth ral stonl' (.... Mi..l.·JlhnK imJgl~ and drtl'ldl1.., pd~e 17M.

·t·

Hint: De not mi..tdkl· d melnng <,uppo-.illlry in the rectum for prostanc ralrifirarion!

144

Prostatic calcification ('calculi')

CCI1lifl-J

Fig. 6. /7 -An example ofcalcification in thepros/ale. Nale also the phlebolith adjacent to the left ischial spine.

145

Bilier cekuli Since only around 1O'k of biliary calculi are visible on x- rays, this is a pon r way of Junking fur them. I ~ patients who are clin ically though t to harbour them, ultra ....umd is therefore by far the preferred initial method of in\'l..,.ti~ltion , and a neganve nlm certainly doe, nol exclude them . :-.:~...e rtheless, patients will rontmue to pn......-nt with opacities 01.. an incidental finding in the right uPf'l'r quadrant requmng danncanon and cera..iondl1;.- a problematic ultrasound e\.J.mination ca n be rlanfied with a plain film,

146

Biliarycalculi continued

Fig. 6. 18- Aclusler of opocities intheright upper quodront in 0 middle-aged woman. These oregollstones.

147

-

Biliary calculi con~n.-l

Fig. 6. 19 -Anotherpotient withgallslones inthe cystic dvctand bileduct. Note the Riedel's lobe e)( ~nding over the righl iliac crest (see p. 35). 148

I

Biliary calculi conlinued

Look for (Fig. b.l':l): •

• •

A singll' opadw or clus ter of llpad til~ in the RUQ or right flank . Gallstont'!' rna}' be single or multiple, I.l rgt>or wry small. Their appea rann- may be

\'t.'ry variable Evidenceot a laminated or fMrlt'd structure, i.e. concentricrings llT polygonal ~pt'S Jut' to abutment of stonl;'!; one upun another hidffiCt" of co-tat cartilagt' cakification/l\"ILJl stone formation on both sidt'" of tho! abdomen which may be mistah'fl for bilidry calruli ..... hen seen on the ri,l;hl. But remember that renal and bil iary stones can coe xis t, dod the gallbladder Ii6 in frunt (If the ri~h t kidney.

Gallstones

1A9

Biliary calculi cor>h"u«J Help ful hints

• • •

• •

Ask for d prone ob lique right upfX'r quadrant view. This will often Isolate

calcuh in the gallbladder, especially if they art' near the spine, and abo cut down scatter from J full abdominal film, giving beucr clarity and contrast. Look lower down than just the right upJ"-'r quadrant. The gallbladder mdY be low-lying bccauseof ,1 big liver, or b eon a wry lung cysticduct , Occastonallv it m.1Yeven lit' in the pt.'lvi;;, A lateral view may help, as gallstone, will tend to lit' anteriorly and kidney stone, posteriorly, but the film must N' suffkil'ntly penetrated. An erect abdomina! film m,ly caus•.' small calculi III undergo 'I.lYl'ring', i.e. til form ,1 small horizontalline as they flU'll in the bilt', The gallbladder m.lY be contracted, however; and prevent this fmm h.lppt.'ning if dL"'t'<1....-d or if the patient has just ...It e n, Remember that SOffit' stones are UII the edge of visibility and by nil means obvious and the V,lSt m,l ~lr ity (4(J'l ) an- invisible ,my way, due toa I,Kk of calcified content.

These techmqce, may N' helpful in dernonstratmg bih<1T)' calculi.

Pancreatic calcification Look for (Fig,6,20): • Fine punctate foci of calcification lying (rom the right of the uppt.' r lumbar spine p.t...sing upward s and obliquely to the left to the region of the splenic hilum, g em embcn

• •

•

Thi" m,1Yno. wry f,lln! ,Ill.! difficult to ...... '111 plain film" and may only show up on ultrasou nd, or particularlv CT. TIlt' absence of \'isihll' pancreatic calcification doc-, not exclude chronic pancreatitis. Cakiftcation of the p.lnrrt',ls m,ly also orru r ill cysuc fibro'iis. and Ol:C,I'illlllJlly with tumours.

150

I

Pancreatic calc ification conri~ued

fig. 6.20 - CalciFiecJ pancreas [umbor spine film . Middle-aged mon with long

history of alcoholism presenting with recurrent bouls of abdominal and back pain. This is a calcified pancreas, indicating chronic pancreatitis.

151

-

Calcified lymph node,- again See Figure 1.U'. Incidental finding (If extensive lymph node cah-iflcatlon, cause unknown. Noll' the potential diffirulties if louking for coedstom renal Of bili'lry calculi. Because one (IT two calcified lymph nodes are S<.l rornmon lin abdominal Xrays they ere u~ually regarded as inert incidental findings without current clinical significann>, but there an- de finite pathological G1U~"S. Remem ber.

• • • •

Hislupl,l"mosis Filariasis

Lymphoma (f'\1S1tht'rapy) - t'Spt-'Cially retroperitoneal Calcifying metastases
Megahint : Ma ke SU Tt' you know whether O T not the patien t has hold ,1 lymphogram within the 1,1SI year, ,IS this willlead 10 pe rsisten tly pl't1cifilli but 110/ calcified lymph nodes in the retropen toncum , althtlugh they may look the same• •swi ng to n-taincd contrast mediu m. Th i!>. however; will pnljo;n'!>siwly disappear over about 12 months hut Iymphll);r'lms are roUdy done in thl.' UK these d'I}"S. II is p ara-aortic and paracavalnodes thdtOP.lCify at lymphography, t.e. onl y tho..e over and adjan'nt to the spin e. Thos e further out
The adrenals The normal adrenals ,In' not vi..iblc on plain abdominal X-r.1 ~ . ... nd tumours of these stru ct u res are on ly visible when significantly enlargt...l OT calcified. P,l li,'nts with suspec ted adrenal disease should ~ll din'elly til ultrasound, CT, \I RI or red ionuclice imaging. Ca lcifi, -d ad rt'U.lls on plai n X-rays mean Iiltl.... in terms llf di,lgnllSis. ...s mll.,1 patit'nb with calcilir-d,ldn'flals do !llll have Addison's d isease, and vice \'t'J'<;J . Nevert hek-ss, it is instructional til n 'c-ognizc th,'S., for what they are an d to un derstand the causes.

152

The odrencls continued

Fig. 6.21 -IVUFilm. There isfaint excretion of con /ros/ medium in thecol/ee/ing systems. Ineiden /ol finding of bilateral adrenal calcification. The patienl hod no relevanl symptoms or signs.

Bilateral adrenal cakificolion

•

Hil('m(lrrh,\~t' tncona tal, perinatal lIT l,l lt" ), eg syndrome Tuberculosis Histoplacmosfs

• •

Amvloid Neopl.l..m, e.g. gangliom.'UnllTld, carcinoma

• • •

Phdt'tl("hnlflll.-;,· loma Wolrndn's di~',l'-t' Ifamilial \ otnthtllThllO"bl AJJi....-n'... di .....·aS(' (Tall'lyl.

•

•

Wa tl'rhllu~' -

Friederich-en

153

Cater 7

The female abdomen Ap.lTl fro m its d isti nct bon y co nfigu ration bt·jng wider for tht' purptl!it.'!' of childb irth, (wl,l in path ologica l entities unique to the female pelvis may p reen: themselves on plain abdominal x -r.ws. TIlt'SI' cons ist pr imaril y (If masses with O f wi tho ut calci fication, tilt' config uration of the latte r w hen prese nt USU<11Jy helping III nar row down the Ji,lgnosis. NB The l MP at any woma n of childbe aring age sho uld be k nown before sub jecting her to irradia tio n of the abd om en . It sho uld also hi' known 10 ,my observe r who att empts to interpn-t any female patient's X-r'IY. vcey rarely woul d ,1 pregna nt abdomen be dl'1ibt'r,ltd y X-TaYN - t'.g, after trauma Of it 'one- shot' [VU. Tubal di~ /or dir-eolll,lining vaginal l<1mptlnS may ind ie.lIe thai the pa tieru has been stenllzed or is undl'fKoing the current lMP, rbpt-'ctiw\y. The qUNion 'Do you think you could N' pn'gndnt?', n-'luin'S ,1 firm nt'/oi,lliw before 1.1l..illg ,my X-rdYs. Remember that one abdominal X-ray equal-, 21' chest X-rays or and a half months of background radiation dose.

"i'

Caus es of mJs ses in the female pelvi s • Voluminou s bladder bonw women «Ill hold up In 2 1i Ifl'S) • Enlargt'lJ u terus (look for fl'l.ll parts /rht-'(k LMPJ,consider haomatocolpos in a yllung female ch ild • Uterine libnud tcatonen (~'t' Hg. 7.1) • Ovarian m,l"St'!'. Benign cy ~t "/ n l'orl d s m " - may become w ry largt' .md

•

calcifv Haematoma tatter trauma!

•

A~l">S (pos!tlpt' r,l!iw ) -

•

P~lCTJI rneningocoeh-.

154

1(1('1.. fur pl)(kt·!s of gJs

The female abdomen

co"'i"uoo

Fig_7.1 -A58-yeordd womon with a hugecraggy moss palpable in /he lower abdomen. The X-roy shows heavygranular calciFicalion. This is due to multiple odiocent uterine fibroids . No,etheincidental Finding of gollstones in the right upperquadrant.

155

-

The femal e ab dome n

COIl/,".....d

TIll' prl.'ft'moJ initial method IIf inve..hg,ltion l,f J pelvic m
tube clips

Fig 7.2 - A woman of childbearing age in whom Ihere hod been severol unsuccessful ottempl$ at sterilization. If ultrasound connol locote them, conventional radiography moy s/ill be required wilhdue regard 10 !hepossibility of pregnancy. 156

Cater 8

Abdominal trauma Ireuma to the abdomen may have important TadioJI1);iCiII m.mif~t.ltion.", which it ill important to know about. The-e coin 1::>0.. d ivided into p'-'Ildr'llin);; injurit..., "'1\h nt'd "h'nb to retained swabs or forceps after operations. t\l'\"l'r think til abdominal trauma in Isol.uton and 10the exclusion of a ll l'ist>, but always as just one .m ',l of wh.lt may wd l be a mu ltiply injuTI...t pa tien t: CIInwl"!'dy, if iI head injury dominates the d ink ,11 picture, ta ke full account of tllat bul do not fllrgt'l to consider tb at the abdomen an d chest m.lY haw been injutt'l.! ,h \\'(']1. Stll",amint> both c.I rd u ll~v and. if 1Il'n 'Ss.U') ', !/;t'l them both imaged. An early triage of the p atiem will of COUN' be m'(t"'~ry to de termine thl"I'ltost seqUl'fK1.' of im 't'!>ti!/;,ltiw procedure, but each trauma centre will h J W its ow n protocol. In evalcanng x -rays for abdommal traumalook for: •

The p,llit'lIl'S name. Establish ,b quickly

olS

po..~ibll' the

p,l tient'~

identitv fnr

bothmedical and medico-legal reasons. Unconscious casualties m.1Y initiallv have III be labelled .1S ' unknown' or ' Mr X, Get the name on the films as soon as possible as mu ltiple 'unknowns' nld~' cudden jv flood in, e.g. after J major molorw,ly accident or rail era-h. lm din!/; 10 potential mix-ups, The lime of the film h',g . lJO pm t. Multiple '#.'ri,ll X-r,tys molY be required following admiss ion ,1111.1 the subsequent tempora l sl't1ut'nce milY be importa nt in follow ing events. ,101.1 thl' .lollI'S on ,111 the films willbe the s ame, unless thl'Y cruss over midnight. Also • Chec k what is left and right. Do not mista ke iI norma l liver for an injured spleen by failing to do thi .., or miwi,l!/;ntl'>t' !/;as under tht' ' rig ht; berm•

157

-

Abdominal trauma «lII~nlldd

diaphragm from seeing it normal ..tcmach Oil ,1 film you h,1\'1;' put up h.ld. to front. (Null' how frl'lllwn tly they dolhb Oil medical TV "'Mp", ,10<1 ,'\','11 reat medi cal

•

p~r.lmml'S -

occ,l.,ionally even UpsiJl' down! )

M,Il..e gOlld uscof the chest x-ray, which will almo.. t rertainlv haw b-en taken .IS well ; if not , then request one. The, m,ly help to resolve co nfu sing Uppt'r abdominal findings. (If both recent OI1"l'I and prl'-l'xisling Jbt',ISt',.h well ,I" ils..i.,tingthe .In.ll..,t hl'li..t pn·I,IJ'l'T,'lin-ly. M,ITt' than ever now is the time In look ran-fullv ,It the skele tnnto check fur

•

fu cluTe'i and d ispla ce me nt 1' ( h\'ny stru ctun.... The cnn firrnatkm Ilf such findings will indicate the -everuy (If injury and the likt'ly lITg,ms involved . e.g. ldt lower nbs: ~pll'l'n; and pelvic bon es : the bladder. look for.

•

• •

•

158

Free gilS in the peritoneal cavity. This will indicate It\\.' rupture (If il hollow viscus ora pml'traling injury 'If pM I of the I;u\' inJic,}ting the nt'Ct'ssity for urgent surgery. 1J0 not f"rgt't Ih,}1 colonic interposition and other pht'nomt'nd m,ly mimic a pneurnoperitoneurn, but look for the 'double- wall sign ' (st't' P.lgl' R'l) as I'll'll as for air under the d i,lp hrdgm . Remember: seriously ill poltit'nts m,ly not be fit for erect film~, in whic h C,l st' ,1 ll'il or rij;hl decubitus vtew m,ly be attempted and free /;i,ISsough t in the flanks, but all the didgmJ!;tir wo rk-up may have to hI' done on supine films alone if lhl' patient Is nul fit even for this, so familiarize ynursdf wit h Iht' sup ine m,m ift'st,ll ions of free alr for this eventuality 1St'!' ....ction on pneumoperiton eum, p. Ii':!!C ,l.. m the I\'lr"f'l'ril"nt'um, (So.'l' ChJ ptt'r -I, p . 100). i\ stab in the back or rt'tl'l,lpt'rilon",ll ru pture of lh(' bowel m,ly occur without visible air in llll' pt'rit,mt'JI ravuy, UJI, II.. for irn");ul,}routlim-s oi d ,nl.. air dl'nsitil~ around the fNl.-ls O1u....·I,">, kiJ lwys and diaph r.rgr rutlc mJ rgins. Appan-nt enlargemcnt of normal org.lns ..uch as the liver, splt'l'n and lidnt'ys - this m,ly indicate subcapsular h.n-matoma formation nr ,'\ '1'11 rupture of these urBans, " Spt-'ri .l l1 y if th..ir no rma l outlin..s have been lust. Such colkcttons can bt, mols.sin' and ran bt· Jia);nnst'tl hy displacement of the bmwl Irom lark of normal ~dS in tfu...... IOI'.lIinns, Loss of the fNlolS ma rgi ns. When this is seen in the context of trauma it is likt' ly III I\·rn.....·nt a m,lS"iw retn'pt'ritont',l! haematoma, inJicatin~ Sl'wn' in jury ,md bluud 111ss. Ll1uk for fr,ld u~ in till' lr,lllSWT'Sl' rrx)(t'sst">, Sl'Hliosis 1'\lI\C,l\"1' totht' inju rtoJ sidl', ,111.1 e\"id..nn' ni btul )' injuri~ in tht' Ill\w nnlJ!;1 ribs.

Abdominal trau ma conli,.1lftd

u

"

•

Be aware that trauma can cause secondary ileus and a l,lrgl' accumulation uf ga~,

which call int~rft'I\' with trauma asses..mcnt. Dispbn'ml'nt of holh ....v organs, ",.g. the stomach med ially ,\IlJ down ....',mls with an l'nl.uging spleen, or upward displacement of small bowel loops nut of the rl.'1vis with a ruptured bladder, Check abo for an overloaded bladder and catheterize the patient, if not ,'llft',ldy dune, III rdil'w Ihb and monitor

•

n

,

"

F"-I!'>~ihll'

r

h.remaruna and urine output

sub~'\jut'nlly.

Flll\'i~n

bodies, "'.g. buill'!" in the USA and lither countries where gUll!>
•

Cruclol Ic cts to remem ber • •

•

•

• • •

•

A normal initial X-r,ly doc, not exclude sign ific,m! intra-abdominal trauma, X-ray,;.ln' iu:-! one mod'llity in the im,l~in~ armamentarium used in Irau nM, aJthlllli:h in s-ome parts of tht, world tht'Y may be the Imly1I11i'. Urgent and ""uly ultrasound - or bet ter, CT -cmnmg - m,ly bepreferableto Sol\l' time in critically injured patients in evalu.utng, for example, the liver and spleen, and remember that del'lYloJ rupture of the splt'l'n in parlkul,u can occur. Injury to the p.mcR'a" le,ldin~ to traumatic p.mel't>,lIitis m,ly often be unrovered hy CT, and colour Doppler aura-ound m,ly conttrm or exclude j.ll'rfusiOll of org.-ms and limbs. The head , rhl'sl, abdomen and limbs ran bt, r,lpiJly scanned in ,1 sri r,11 CT machine, although l~st'llti,ll imrnnbihz.ttion/anae-thetic devices m,ly slow things down d hit. f..l.rly rm~I't'SS to evcreuon unwarhy, un'thn~rarhy or artl'riography m,l~' hi> an urgt'nl and nece-sary follow-nil from plain X-ray" in the cveluauon (If trauma. \ fRI m,ly be urgt'llt ly required to assess Srin,lllrdUm,l. 0 0 nol unne cessarily tak e out a patient 's fun ctioni ng kid ney: he may onl)" have the one, You must make t'H'ry dfurl ttl establish the r~'nn' or othl'rwist>of another wnrking kjdnev before Idking out tht' only one he or she h,lS,and rem ember tll.ll kidneys h,I\'I' remarkable ptlwl'r" of rt'gt'nt'r,ltiI11l. And wnsidt'r this for ,my injufl'll kidnt'y : '\Vnuld l ctill t,lh' out this injured kidnt'y if I knew it w,l" thl'nnl~' one?' 0 0 nol wacte lime with imaging if th e palient is bleed in g 10d ea th in fmn t of you . Rc-uscttation mu-t come fir-t , and after that in "omt' r,lst-, immediate

159

Abdomi nal tra uma con bnved transfer to theatre may be required , and if nl'Cl'Ss.lry X-r,lYs undertaken only then .u the discretion of a senior doctor.

Trauma : rcpn ned kid ney Noll' (Fig. 8.1):

•

• • •

The swelling (If the right kidney The t'SCapt> 01contrast trorn Iht, right a,lll'Cting system, indicating rup ture of tlu- kidnt'y. A I,Uj;I' volume of hh ...Jd is escaping as well. The scoliosis concave to the injuft'd side (ind irect sign) And most imrnrt,mtly: another normally (,ll.cn'ting kidney . >1\ the opposite side .

Footnote : Escape of ('onIT.1S1like this can occur in severe rena! obs truc tion ill the acute setting.or also in the chronic Sl'tting where ill-an form a huge fl'lfllpt.'ri lont>dl flu id conecnon called
160

Abdominal trauma mnlinued

y

,f

r

Fig_ 8_' - This is on IVU Film oJ a potienllided in till! right Ronl in a fight. The pklinFilm showed loss of the right renol and p500S outlines.

f61

Abd ominal trauma conhnued O ld trauma

Fig. 8,2 - APsupine radiograph of on oldsoldierwho'slopped one ' during /he Normandy ca mpaig n in '944. The leN pubic ring and right sacral wing hod been smashed by the bvlle', which then tumbled and come resl beside /he right femur in 'he groin . Evidence of old trauma may occasionally present on abdominal films ca using confusing bone changes,

'0

162

Multi Ie in'urie5: thorococbdominol trauma Lo...k for (Fig. IU ): •

• • •

Compl..'ll' '*'p.lT,llilln uf thelower thoracic spine and corres pond ing ribs Ruptuwof the It'ft hernidiaphragm with lol'f'dTation from the cht'Sl wall

•

Fractures of the urf'l'T nb, and bilateral sUf);ical emphvsema Colon in the Chl.'S1 left N 't,1I pnt'Umolhoral< Di~t of IhI.' twart 10 IhI.' righl

•

Sandhd~ ~t.IN lizi ng the head .

•

Tbe child died from o't'.i~it'n t w \"t'n.' ht-ad injun..,...

Fig, 8,3- Child aged 4 years who was thrownoutofocar when ilhilo free. No seal bell. SuHered severe multiple in;uries andhlled. 163

Cater 9

latrogen ic objects Radiological ln this age (If well-developed intervenhonal prOCNUTt'S in radiology it is common In see objects that have been deliberately placed in the abdom en 10treat disorders in most systems. Being able to recognize SOffit' of these for what they are will enable you to deduce what has been w nlllg with and done 10 you r patients. The posi tion of these dl;'viCl'S may abo be monitored by plain X-rays to confirm that they are still in position and h,\V1;' not slipped, leading to malfun r tion .

Typical devices to look for include: •

Aortic/ iliac stents for vascular stenoses - with wire mesh structures in the line of arteries Biliary!urin,lfy /G I tract stents for stenoses - ('l;'1;ophagus/rectum/sigmoid Temporary ru-phrostomy tubes to decomp ress obstructed kidneys often with pigt,lib 10 aid posi tion reten tion

• • • • •

Abscess drainage tubes Inferio r vena cava filte rs Ito p revent pulmonary emboli from the legs) Embolization coils/balloons - 10 ablate vessels in tumours prio r to or ,1" an alternative to surgery, and to shut down pathological circulations.

Retained con tras t medi um This m,ly also be seen in the appendix or colonic diverticula (barium) and in the spinal canal (myodill - with round blobs of this high densi ty agent Irom previous mye1ogr,lphy examinations. It may even exten d right up to the head.

164

Rodiologicol l;OtttitNled

I Fig. 9 , -Inferior vena cava (1Irer_ 16'

Radiological con,inved

I

Stent

Fig 9.2 - RighIexternal iliac $1ent.

166

Medical/surgical accessories Ahost (If other objects,lSSIICi<11l'l.l with P.1S1 or currenttherapy or previous surg~f)' may also present themselves on abdominal x -rays. Look for:

•

Surgic.ll sutu re... or clips, oftl'" tiny and hard In st't' u nless made of d ense

material •

NJ>l.l);dslric tube; in the stomach (usu,lIly with an oPJlJUl' hpj. These ca n cu rl

•

up in the nose, pharynx or oesophagus, back-track up the oesophagus, or gct knotted in thl' slllmJch! They INy even be lying down the right or left main bronchus! Cet views of the head or neck if the tubes han' not reached the stomach Small tlpilrilit... ever buttock am'S tprt>\'iuUS bismuth injt'ctions or crysldllint"

penidlltn for VD tote.) •

• • • •

• • • • • • •

• • •

•

ECG IN,h - Uppt'T dbdoiT\l;'n/lowl;'l' chest Wire. from TENS machines It) control pain Cutaneous p.ltehl... (nkotine, hormones ctc.)

Ventrirulopcrilont'al ..hunls (hydnlCt'phalus)- don't misldkl" for M"'Ogd'iotriC tubt-s! Tht-yotten lie over the medial lung fid.h dOO all' outwith the stomach. Syringe driver tUM (morphine t'tc.) P.:ICl'miIM'r'io Tantalum gewe [previous surpcall'l'JXlif'io - gmin /umbilicus) Pt'S~ry rings - uterine pmlap,e. Fallopian tube eli£,!, Radoacnve seeds. t'.g. in pelvis ~ll'lill hip pro-thee-, Itum previous fractures 10 the TK'Ck of the femur Prosthrlic heart vain... - stlmt1iml'" visible on upper part of abdominal filmUmbilical catheters (childn'fl) Bladder catheters Intrauterine contraceptive devices (pdvis) Rl'Ct'fltly ingt.."tl'li pills.

167

Medical/surgical cccessones COfIl inued

Fig. 9.3 - This potient hod very srrong steeisullJres putin For an anterior abdominal

wall incisionalhernia.

168

Medical/surgical accessories conlinued

Fig, 9.4 - Mtxe 'wrgical lootsreps'! Tontolvm gauze used 10 treat a II'f:fItroi hemia.

Sometimes it con o/so be found in the groin leN herniorrhaphy repairs_ II .breoh For 0 reIoinecJ swab'

lfI with time. Don't m;sloke it

169

Cater 10

Foreign bodies, artefacts, misleading images There is no end to the lbt of foreign bodies that may end up inside a patient's abdomen, and this i;; particularly true of children. Typically ingested objects include coins, beads. ball bearings, toys,safety pins, ring-pulls, mercury batteries etc. Some foreign bodies will be poorly seen, e,g an aluminium ring-pull, and some may be completely invisible, such as a sma ll rubber ball. It is important to view the child as a whole and not simply the stomach in isolation, that is, the ears, nose, mouth and pharynx should be checked clinically, and ..my history of stuffing foreign bodies into ,my other orifices, as well a, swallowing them, should be sought, ()r even other children's orifices'! Depending on the timescale it m,ly be expedient to X-ray the child from the level of the nasopharynx to the rectum in one go, as a foreign body may lodge temporarily in the lower oesophagus and may be missed if only an abdominal X-rayis taken. Later, when the child feelsdiscomfort in the lower oesophagus but the foreign body moves into the stomach, it may he missed on iI chest X-ray taken later only to pass on when it has apparently been 'excluded' but between the temporal scx.\Ul·nce of the two films has actually ~....-n missed. Due regard 10 minimizing radiation dose must, however, he constantly borne in mind. But X-rays may be nl'Cl'Ssary 10prow a foreign body has passed.

\ 70

Foreign bodies, artefa cts, misleading imcges conllnued

fig. 10./ - Pwchiatric patient who enjoyed meals of mercury and gloss thermome'ers. Nole also /he razor bladein theleNupper quadrant - these are usually wrapped in sello'ope by thepatient, but are notvisible radiologically. The nurses in this potien(s word got into trouble because thermome'ers kept disappearing. The chest X·ray showed multiple small mercury globules which hod been inhaled into /he lungs when thepatient crunched /he thermome'ers. 17 1

Foreign bod ies, arte facts, mislead ing ima ges

conhnued

Adults, especially if subnormal, may ingest all manne r of strange objects. and of course insert all manner of objects into their rectums. Criminals and drug smugglers lThIy swallow sachets of heroin or other drugs. or stuff them in their children's soft toys. Occasionally multiple small speckled opacities may be seen in the abdomen. These can be anything frum pica (dirt, stones etc.), eggshells, broken den tal fillings. to lead p aint - the latter having diagnostic sij!;nificance when lead poisoning is being sought. Apart from entertain ment value the most important fact to consider with an ingested foreign body is, will it pass spontilm'ously (e.g. a small ball bearing) or will it not (e.g. an open safety pin)? The decision must then be made whether to wait, watch and review (if necessa ry with a follow-up X-rayl, or intervene endoscopically or surgically to retrieve it. Psychiatric ad vice may also De appropriate in some cases.

172

Foreign bodies, ortefo cts, misleoding imoges

COt1hnueJ

Fig. 10.2- Engagementring swallowed by yoong child. The insurance company would nol pay up as theowner 'knew where it was' and so by definition it was notlost. Should pass sponfonecwsly. The diomonds, being reol, didnol show up osthey are mode of carbon!

173

Foreig n bodies, artefacts, misleading images con ,inuoo

Fig, 10,3 - An adult male pre5enting with rectal pain andbleeding, This abiecl wcs an old'5tyle gla55 radio valve which he claimed fa have 'sat on', as such patienlsoften do. II wasimpacled disfal/y into theonal mUC05a by it5 prong5. The main problems are: • • • •

174

How 10 extract tbc foreign bod y without breaking it or lacerating the mucosa Minimiz ing the danger 10 your self regarding HIV, hl'p.'Itili ~, sep ticaernia etc. Minimizing the d.mgcr 10 the patient Cont rulling your own and your staff's mirth in dealing with such d patient-. you must learn 10 keep a stra igh t face in suc h circ u m stances, a nd be sympathetic toward s the p,ltil'nt' s embarassment and plight.

Fore ign bodie s, artefa cts, misleading imoges

con,in.-l

Fig. 10_4 - Eldetly potientpresenling wirh rightupperquodrant poin and swpeded cokulovs cho/ecyshlis. Note the four opocWes in linein the ROO.

• •

These an- all identical in size , ~hapt> and dt'ltSity. all." never ~l perfect. ?Artefact~ _

GaIl~ttmt'S

These turned our to be pandrops in a bag in the p.lhent's pocket! The opacities had g\Jne a fter the hag o j ~\\"t'(1~ was removed for the repea t film . Note the punctate costal caTtilaj.W calcitications. ~B The patien t could still have had cholt'CY"htis wi th nOn--opil\!Ut' gallstone, and stillrequired invest igation .

175

Fore ign bodies, c nelc cts. mislea ding images COI1tin ued

Fig. 10.5 - Soft tissue shadow of penis simulating a calculus in a young mole patienr. learn 10 recognize Ihis to ovoidmaking 0 fool of yourself byasking whot itis on the wordround. Another example is shown in Fig. '.2.

176

Cater 11

The acute abdomen U"~

The most important cau~ of an acute abdomen which It\iIy be associated v.;lh p1din film Tildiological signs incfude; •

Perforated viscus h-:;pt.'Cially

iI

duodenal ulcer, but any part of the GI tract

may ruptuf1'I, with ptoritonitis

• •

Ruptured aortic ant'ury..m Renal colic

•

Bili.Jry colic

•

Acute cholecystitis

• •

Acute piIllCTt'iltiti" Acuteappendmtis

• • •

Intt'Stincll (~tructi(lU Acutediwrticulili!'> volvulus

•

Hernias

• • • •

Absce-es Vascular occlusion." Intussusception TOKie dilatation of colon.

00 not forgt'!, however, to view the patient as a whole to take a ch('!ot X.u y and remember that •

Myocard i.ll infarrtton

• Ba~l pneumonia • Dis>ecting aorla •

Pulmonary embolism etc. m,ly all m asquera de as an acute abdomen.

177

The acute abd omen

con~n.-J

Remember also that tht' r.ldioll1gical signs may not be present or fully evolved attbe time of presentation, so if nerr-,"'uy re X-ray the patient afteran hour or so, or move on rapidly to ultrasound, CT, IVU, angiography or whatever is appropriate to ~t,lh1ish the diagnosi.. withou t dday. Ora l water-soluble contrast or recta l contrast may bot' given 10 confirm or exclude visible t'\idt'nn' of leakage or obstruction in appropria te circumstances. but thb should only be after diSl"Ussion with the radiologb;t. Remember also the many cau sl's of acute lower abdominal pain due to g)'nal'colt>gicaldi!'o(ll\h-r- in women. e.g. dysrrwnorrhoea, Sdlpingitb, ovarian <)-.;t torsion etc.

Remember in addition to the above common medical conditions that simu late an acute abdomen tm' other rarer medical ( .l USt'S of acute abdominal pain , such as porphyria, Addisonian crisis, diabehc crisis. and lead poisoning eec.!

178

C a fer 12

\

Hints •

Never forgl110 check tht' nam e,m d the da te first and gl't all the other datil can t,ff the nanu- b.hJgt>. Film~ can "d~ily gt'l in the "TOng f"ld.t1~!

~'OU

•

Check male or It'milk

• •

Check ldl and right. Makt' sun' l'n-rything is on the film, trom the bcmidiaphragms to theinguinal

•

canals, or covered by Sf.'\'t>fal film... ~ Idk{'sul\' you under..tand bow the film was taken, te. erect, supine.decubitus.

• •

• • • • •

•

• •

• •

Of oblique, and 1M! yuu understand the implications of each position and what to evpect . e.g. fluid levels do nt)l: i1Pf'l'ar on surim' films. You see what you Ill1l1.. Ior - don't underestima te the 'mark 1l.')"cNU'! In acute abdomens always gl>t a chest X-ray, prdl'rably erect. Remember thai ~ous Chl~1 ueea-e 11'Ld~' mimic serious abdominal disease, and vice versa , ~OnJdry X-Tdy ch.Jngl-.lo abdominal disease lThly occur in the cbesr. Cht'CkIhl! lung base, and luu!.. fur the breasts on abdominal films. Find the tee-e, a nd you've fuund the colon. Acquire previou-, film!' a~ soon ol~ pu·.siblt' to rompare with new ones. ~lol!..t' ..un- you've put rhe film up the right way round! Only view films under prtlpt'r conditions of illumination, i.e. on a \it""ing box, wa\in~ them in Imnt of a window on 01 ward round ....ill guara ntee Yt1U will mi....20'{ of what there is to see. Put a bright light beh ind any area too ddr!.. to eee properly on the viewing box. Sod's WI'.' will always conceal a sign ificant abnormality in a wry da rk area e.g. rib frartun.... Y"U must be abletn exp lain l-'\'t'I),thing yuu see o n a film in terms uf anatomy, fI,u ly. 'Not hing l'~cl u dt'S ,lilYthing' i.s 01 good working aphorism. Life-threatening 179

Hints con'inved

•

iIInt">S mdf be pr~'nt with no or onl y J few radiological ~i~n~. R ules Me for the obedienceof foob and the guidilncel1f wise men'. l.c. do not stick ~liI\'ishly to protocols. Adju ..t f our actions ilppropriJtd y til the patient's

•

prtlblt'm~, and keep a globdl vtew of the patient at all times. when in doubt, do tlK> right thing_lilt' ca lling a radiologi..t at 2 a.rn. 'Every woman is pregnant until proved otherwise'. Gt.'t the LMP before

• • •

•

•

• •

1"l't.JuI...ting X-rd~~. Keep en opt.'fImind , Remember the Omcl'p1 of differential diJgnIJSi.., Do nilt be boxed in by otht.'t pt.....ple,' "U..f't'CIN labels and diagnc......... Le arn to work out the ilgt' of patients from the dpp"'ilTdtlCl' I" tht'ir films (i.e. fn>m vascularcalcification, dl~l'T'lt1'ilti\"l' "pil\ill changes. curti("althinnin~ times of l'Pirhysml closure etc.) , and cross-check it with the date of birth and the date the film was ta ken. M,lint.lin J sceptical outlook Oil all d,lta supplied. l;.'lt / right markers can be incor rect and the wrong names gt'! lin patients' films. 'Check fur An",s error.' 'tour p.llil'nt may deny previous SU!"HI'ry bu t han' Win.' su lu rl'" visible. Have you got somebod y else's film in yo ur hand, or is your patient demented ? Learn to look, th ink and .utku l,lll'/discuss the findings o n X-r.IY films simu lt,ll1"ously. Th i.. take, m,my YI'.u's to perfect, bu t nnw is the time to ..tart. Minimise the rad iation dl""l' h' p.llil'nt" by tilking no mort' films than nl'('t'Ss,ny.

•

To '*'t' fluid Irt>eIs you need fluid, ,11<1' and an t'Tt'f1 or ,huMus him, with a horizontal X-ray beam. Su pirll' films are done with a vertical beam.

• •

Do not create chaos hy misinterpreting tantalum golUll'as a retained s.....ab. &'wal"l' of be..... el gas. It r a n hide .lny abnormality and simulate I)'lic bone disease. Al......lys remember that you r clinical diagnosis m.-.y be U'7\''';{. DIl not dl·wlop .In idee fi'ti every time ~·ou lOll\';' at a film. Remember theconcept of Jijfrrt'ntidl diagnosis and be receptive tomformanen which may contradict your fiN impression on the x-rays. The pat ients don't read the te... tbooKs - they \\;11 not always pn-ent wuh all the symptnms and signs of a particular condition,

•

• •

Practise louking et X-ray films in boob, journals, compu ter pn'>gramml"', the lntern et etc. and 'present' them verte uy 10 yourwlf or other medical ..lud l'ntsl colleagues until this becomes second nature.

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Do not have J pa ssive a lt itude 10 radiograp hs. If they ar e technically unacceptable gl't them repeated . JS long as it is clinically ;USlifil'lJ .

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Understand the limitations of X·r ay films: se nous disease ( an still be prt'St'nt

180

Hints co n,inlJfld with J nl'g,lliw film, but som eon e 1:'1St' mily see signs w hich yo u have no t seen. By definition we do not kno w what we have missed - until the pust mortem! The s anw film ran 10111. dramatically differe nt on another occasion, or if just d little bit mort' clinical infurmafion is supplledor ano ther view is taken .

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Remem ber that X-rolY;; litl not provide answers in en'f}' case. Learn to idcnn ly a cillcifit'J aorta over the spine, whether normal or aneurysmal. This must become a n·f] "l<. In {'\ "t"!'Y0llt' OWl' .wcn..'Ck for Ant.·urysms. Aneurysms, Ant."UI)'sm.~- the 'triple A' of [R. i.e.•AbJ"min.tl A"rtio.:

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Allt'u rpm..~ · .

You mdY save

,h., f'dLitc-lII's lif"".

Pic" d favourite organ in ,h.' abdomen that you lOCI'" for ~pt.'ddlly in I:'vt.'lj' patien t. Look criticdlly dt idITll);I·nic ubjl'Cb suc h .1" nd",,-~slric tubes. Do nol a....s u me that because tht.'y were put in by 't.'\ pt'f1s' thL~' are in the right place. Orten t~· are nol , or Ihl'y may M\"I;' moved. Check again-..I PT\'\;OUS films .

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Sma ll fluid It'l.t>l.. can l >CCUC normally. Gl"t a hislory l,f any previous ..urgl'ry before trying 10 interpret any X-ray film and make sun' you record il on the request for the radiologi..1.

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Oonol mi"lolUo a stoma for an abnormal mass . If time all ow.., T\' X-coly the patient atter a period of time. 10 allow an y rad iolo~ica l change, 10 e\ ·oln>. Do not waste time with abdominal X-cays in crincallv ill patients. If ind icated, go siraigh l 10 abdominal CT ~anning or theatre for immt'dialt' surgical mtervennon re.g. ruptured aortic aneurysm).

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Do m>l sit rock a nd wail tor somt.'thing to JUmpnut at you from the film dod if mllhing dOt'!> "'ll ra il il 'norm al'. warn the rdd il,logiral sig ns of abnormality then go looting for them Milk Ihe film YllU'W got bdon' dsk ing for another one. TIlt' d iilW1IJSis of norma lity is an important co nclusion to em ve at and is the
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Hints COiIhn""';/ relevant clinical infnrmatiun. This will enable the rad itllt ~i~l to optimize the dia gnosnc value tlf the film s Y~l\I MW requested. Print ytlU r ro m", and gin' you r bleepa nd wa rd num ber clt'Jrl y, so the rad ioll~ ~t can con tact you Mc l with Urgl'Ilt find in~... Panen ts haw d ied becau-e dectors' names were illegible on X-ray form s, Inadequate and iII~iblt> rt'\lUNS are dangerous. mir..leading, ol nno~in~ ol nd n~li gt'Ilt_ Memorize a template so that ~'ou can preent .my X-ray (01"01.' H·rbally. For

•

example: 'This is an H.~£!!!!!!~!!.:~.:~~_Y of.~r.s.'!.'!;1..?.~!!.1.~1. taken on .~..?P~0.I.~

~.f!Q} when sht· was .?L~~~.~..~.('.~. TIlt' positive finding i~ ~.i.~!.,:~!!!~~!.~!!!'.'.~!.!!p'~~.~( and this is consistent with a diffen-ntial diagnosis of .(!!::'.'.~.I.j.~·.li~J.I.'. and H~!!~, of which the rno- t likl'1y is Ht:!r.!~~:~!~:!!.' Fill in the underl ined par ts depending on you r findin~s .

Then wait

fOT

the croo-examrnanon.

And fin ally:

Stay cool! 182