Chest & Abdominal X-ray Interpretation

Lt Col NK Jain Gd Spl (Radiology) MH Jabalpur

The Chest X-Ray

Techniques - Projection
P-A (relation of x-ray beam to patient)

Techniques - Projection (continued)

A-P Supine/Erect

Techniques - Projection (continued)

Lateral

Techniques - Projection (continued)

Lateral Decubitus

Technical Factors

Centering
Penetration Inspiration

Rotation

Rotation

(continued)

Penetration

Inspiration/Expiration

Densities
The big two densities are: (1) WHITE - Bone (2) BLACK - Air The others are: (3) DARK GREY- Fat (4) GREY- Soft tissue/water And if anything Man-made is on the film, it is: (5) BRIGHT WHITE - Man-made

Systematic Approach
Bony Framework Soft Tissues Lung Fields and Hila Diaphragm and Pleural Spaces Mediastinum and Heart Abdomen and Neck

Systematic Approach
Bony Fragments
Ribs Sternum Spine Shoulder girdle Clavicles

Systematic Approach
Soft Tissues
Breast shadows Supraclavicular areas Axillae Tissues along side of breasts

Systematic Approach
Lung Fields and Hila
Hilum
Pulmonary arteries Pulmonary veins

Lungs
Linear and fine nodular shadows of pulmonary vessels

Blood vessels 40% obscured by other tissue

Systematic Approach
Diaphragm and Pleural Surfaces
Diaphragm
Dome-shaped Costophrenic angles

Normal pleura is not visible Interlobar fissures

Systematic Approach
Mediastinum and Heart
Heart size on PA Right side
Inferior vena cava Right atrium Ascending aorta Superior vena cava

Systematic Approach
Mediastinum and Heart
Left side
Left ventricle Left atrium Pulmonary artery Aortic arch Subclavian artery and vein

Heart
Size:

Heart

Size of heart Size of individual chambers of heart Size of pulmonary vessels Evidence of stents, clips, wires and valves Outline of aorta and IVC and SVC

Systematic Approach
Abdomen and Neck
Abdomen
Gastric bubble Air under diaphragm

Neck
Soft tissue mass Air bronchogram

Anatomy

Lobes
Right upper lobe:

Lobes (continued)
Right middle lobe:

Lobes (continued)
Right lower lobe:

Lobes (continued)
Left lower lobe:

Lobes (continued)
Left upper lobe with Lingula:

Lobes (continued)
Lingula:

Lobes (continued)
Left upper lobe - upper division:

Pleura
Layers:

1. Visceral
2. Parietal

Angles: 1. Cardiophrenic 2. Costophrenic

Hilum
Made of:

1. Pulmonary Art.+Veins 2. The Bronchi

Left Hilum higher (max 1-2.5 cm) Identical: size, shape, density

Hilum

The Normal Lateral Chest X-ray

Lateral View:
1. Oblique fissure 2. Horizontal fissure 3. Thoracic spine and retrocardiac space 4. Retrosternal space

Lateral CXR (continued)

Lateral CXR (continued)

Lateral CXR (continued)

Identify the lesion localise the lesion describe the lesion give DD

Never stop looking, carry on with your systematic approach!!

Pathology

The Silhouette Sign

An intra-thoracic radioopacity, if in anatomic contact with a border of heart or aorta, will obscure that border. An intrathoracic lesion not anatomically contiguous with a border or a normal structure will not obliterate that border.

Consolidation
Lobar consolidation:
Alveolar space filled with inflammatory exudate Interstitium and architecture remain intact The airway is patent Radiologically:
A density corresponding to a segment or lobe Airbronchogram, and No significant loss of lung volume

Atelectasis
Loss of air Obstructive atelectasis:
No ventilation to the lobe beyond obstruction Radiologically:
Density corresponding to a segment or lobe Significant loss of volume Compensatory hyperinflation of normal lungs

Practice Time

Right Middle and Left Upper Lobe Pneumonia

Pseudotumor: fluid has filled the minor fissure creating a density that resembles a tumor. Also seen is right pleural effusion

CHF: accentuated interstitial markings, Kerly lines, and an enlarged heart. Normally indistinct upper lobe vessels are prominent but are also masked by interstitial edema.

Chest wall lesion: arising off the chest wall and not the lung

Pleural effusion: Note loss of left hemidiaphragm. Fluid drained via thoracentesis

Lung Mass

Small Pneumothorax: LUL

Metastatic Lung Cancer: multiple nodules seen

Perihilar mass: Hodgkins disease

Widened Mediastinum: Aortic Dissection

Pulmonary artery stenosis with cardiomegally likely secondary to stenosis.

RUL Pneumonia

Pneumothorax

RUL collapse

Air under the diaphragm

Emphysema

Cavitating lesion

Hiatus hernia

Miliary shadowing

Chest Tube, NG Tube, Pulm. artery cath

Abdominal Xrays

The Abdominal X ray

Not used in clinical diagnosis regularly
An AXR

uses 50x the radiation of a plain CXR

Can be plain or contrast study Indications include: Suspected bowel obstruction Foreign body Stones in the renal tract To check position of stents etc

Position of Patient
Supine (lying on their back) with the plate (film) underneath them x rays from front to back
Unless otherwise labelled, the film will probably be supine

Erect may be useful if looking for fluid levels

Decubitus taken with the patient in the lateral position may be useful to detect intraperitoneal gas
Prone - patient lying on their front - occasionally used in IVUs

Interpreting the AXR

Step by Step

Part 1 Patient Details

Name of patient
Age Date of birth Date the radiograph was taken/time Brief info about patient

Part 2- Technical Details

Type AP/PA
- supine/erect/L.decubitus/prone

Orientation of film
Penetration

Rotation
Adequate view

Part 3 Intraluminal gas

Stomach Small intestine (n= 2.5 cm) Colon (n= 5 cm) Caecum (n= 9 cm) Rectum (sometimes visible)

Clinical Findings- Obstruction

Large bowel Peripherally placed dilated bowel Small bowel Centrally placed loops dilated bowel

Haustra (do not cross Valvulae conniventes whole diameter of extend across whole colon; no more than 1/3 bowel lumen of the way across)

Few loops

Many loops

EREC T

Note the multiple fluid levels

Part 4 Extraluminal gas

Gas under diaphragm Gas present in the peritoneum - perforation

Gas under diaphragm

Gas under diaphragm

Perforation

Pneumoperitoneum Supine AXR

Part 5 soft tissue structures

Liver Spleen Pancreas Kidneys Ureters Bladder Psoas muscles

T12 vertebra Kidney

Psoas Descendi ng colon faeces Sacrum Sacroili ac joints

Gas in rectum

Part 6 Abnormal calcification

Aorta Pancreas Cystic Duct Gall bladder Kidneys Ureter Bladder Urethra

Bladder calculi

Renal Stones

Ureteric Calculus

Pancreatic Calcification

Gallstones

Aorta
Walls of AAA

Endovascular aortic aneurysm stent

Part 7 Look at bone structure

Fractures vertebral bodies Metastases Changes in bone density Shape

Fracture

Bone pathologies

Finally- Extra features

Foreign objects ECG leads Tubes/stents Surgical clips aid diagnosis

Then summarise the findings and give possible diagnoses

Summary Presenting
1. 2. 3. 4. 5. 6. 7. 8. 9. Patient Details - easy Technical Details Intraluminal Gas dilated etc. Extraluminal Gas- preforation Soft tissue Structures- -megaly Abnormal Calcification - stones Bony Structures Any Extra Features - objects SUMMARY

NORMAL

Hepatomegaly

Dilated Small Bowel

Stag Horn Calculus

Pneumobilia

Toxic Megacolon

Volvulus

Pancreatic Calcification

Gall Stones

Small Bowel Obstruction

Vesical Calculus

Renal Calculi