Chest - Abdomen Lecture Notes PDF

THE CHEST  IMAGE ANATOMY BASIC REVIEW PROJECTIONS OVERVIEW MODIFIED PATHOLOGY TECHNIQUE BONY ANATOMY Anteriorly Clavicles Sternum Sternocostal a...

THE CHEST  IMAGE ANATOMY BASIC REVIEW PROJECTIONS OVERVIEW MODIFIED PATHOLOGY TECHNIQUE BONY ANATOMY Anteriorly Clavicles Sternum Sternocostal articulations Posteriorly 12 thoracic vertebrae 12 paired ribs Scapulae Posterior view Anterior view Supero-inferior view  1 2 3 1 4 Counting ‘posterior’ ribs 2 Counting ‘anterior’ ribs 5 3 6 7 4 8 5 9 6 10 7 11 8 12 VISCERAL ANATOMY Airway Lungs Mediastinum: Heart Great vessels Diaphragm AIRWAYS Bifurcation/Carina L main bronchus R main bronchus Bronchioles Right hilum Left hilum  RUL RUL LUL RML RML RLL RLL  APEX UPPER ZONE LUL LUL MIDDLE ZONE LOWER ZONE LLL LLL BASE Cardiothoracic ratio  Right Left Posterior costophrenic recess  APEX Right hilum Left hilum BASE * * * Right hemi- Left hemi- * * = Costo-phrenic angles diaphragm diaphragm * = Cardio-phrenic angles  Erect bucky Wall bucky Vertical bucky Upright bucky Table bucky Tray Bucky “In the table” http://incenter.medical.philips.com/doclib/enc/fetch/2000/4504/577242/577261/577263/670329/670330/5162433/452299103 EQUIPMENT 191_DigitalDiagnost_4_1_Specification.pdf%3fnodeid%3d10740235%26vernum%3d-2 SCATTER REMOVAL GRIDS  SCATTER REMOVAL GRIDS https://www.youtube.com/watch?v=obj3wpQfb8s SCATTER REMOVAL GRIDS  GRID TYPES Focused grids (most grids): strips are slightly angled to account for divergent beam- must be used at specific distance Moving/oscillating grids: eliminates the fine grid lines – used within bucky system in x-ray room Virtual grids: no actual grid is used; latest innovation for scatter reduction by digitally reconstructing a radiograph ANTI-SCATTER GRIDS General rules: Exposure must be increased if using grid (usually at least doubling mAs) Do not angle against grid lines Do not place detector back to front in Landscape holder Portrait Do not place grid on back to front Use at a certain FFD ANTI-SCATTER GRIDS ERECT BUCKY Wireless DR detector/CR plate Fixed/stationary or oscillating grid Automatic exposure control (AEC)  AUTOMATIC EXPOSURE CONTROL (AEC) Ionisation chamber is a hollow cell containing air connected to a timer circuit Radiation hits the chamber, and the air inside becomes ionised, creating an electrical charge The electrical charge travels along the wire to the timer circuit and terminates the radiation exposure when a sufficient charge has been received “Sufficient charge” is a predetermined value that helps keep the dose as low as possible to see anatomical detail of the lung The radiographer chooses the AEC chambers that they would like to use- this is determined by the anatomy in question https://radiologykey.com/automatic-exposure-control/ PA LATERAL  ID & Consent Explanation PATIENT Exclude pregnancy PREP Remove clothing & jewellery Patient gown  PA Chest STANDARD CHEST SERIES Lateral Chest  Postero-anterior (PA) BASIC PROJECTIONS The following should be clearly shown: Evidence of proper collimation Entire lung fields from the apices to the costophrenic angles No rotation □ Sternal ends of the clavicles equidistant from the vertebral column □ Trachea visible in the midline □ Equal distance from the vertebral column to the lateral border of the ribs on each side Proper shoulder rotation demonstrated by scapulae projected outside the lung fields Proper inspiration demonstrated by ten posterior ribs visible above the diaphragm. At least one less rib visible on expiration Sharp outlines of heart and diaphragm Faint shadows of the ribs and superior thoracic vertebrae visible through the heart shadow Lung markings visible from the hilum to the periphery of the lung IM AA CREAAPP Radiographic Critique- Chest QUALITY CRITERIA: MARKERS Radiographic anatomical marker (with initials) on correct side and clear of anatomy. MARKERS ? at the time of exposure For deviations from ‘standard’ technique Indicator of patient position Error or medical marvel? THINK ABOUT SIDE MARKER POSITION ARTEFACT On the patient System error Clothing Grid lines Jewelry/money/phone etc. Dead pixels Dirt/food/hair/blood etc. AEC chambers Scatter In the patient Exposure error Medical devices Saturation/burn (over exposure) Penetrating trauma Noise/quantum mottle (under Inhaled/swallowed FB exposure) ARTEFACT QUALITY CRITERIA: ANATOMY Both lungs included from apices to costophrenic angles, ribs, medial clavicles and scapulae and peripheral soft tissues. QUALITY CRITERIA: COLLIMATION AND CENTRING Superior collimation including apex of lung and surrounding soft tissue/ribs. Inferior collimation distal to the costophrenic angles. Lateral collimation close to skin edge. Centered midsagittal plane. QUALITY CRITERIA: POSITIONING Apical lung visible above clavicles. Scapulae projected clear of the lung fields. No rotation o Trachea is midline o Medial ends of the clavicles are equidistant from the spinous processes Good inspiratory effort (8-10 posterior ribs above the diaphragm). ROTATED Medial ends of the clavicles are not equidistant from the spinous processes. Distance on left is greater than right indicating rotation towards the L. Patient presentation: KYPHOTIC Angled, low riding (>5cm apical lung projected above) clavicles Crowding of apical ribs. Sharp rib angles at lateral margins. Chin/head projected over superior chest. QUALITY CRITERIA: EXPOSURE Contrast and density sufficient to visualise bone and soft tissue whilst able to appreciate lung markings to the pleural edge. Faint visualization of bony skeleton through the mediastinum. INSPIRATORY EFFORT  Lateral BASIC PROJECTIONS BASIC PROJECTIONS The following should be clearly shown: Evidence of proper collimation Arm or its soft tissues not overlapping the superior lung field Costophrenic angles and the lower apices of the lungs Hilum in the approximate centre of the radiograph Superimposition of the ribs posterior to the vertebral column Lateral sternum with no rotation Long axis of the lung fields shown in vertical position, without forward or backward leaning Open thoracic intervertebral spaces and intervertebral foramina except in patients with scoliosis Penetration of the lung fields and heart Sharp outlines of heart and diaphragm BASIC PROJECTIONS Left lateral chest. Right lateral chest on same patient. Notice different size of the heart shadows. QUALITY CRITERIA L M: Correct post processed anatomical marker clear of anatomy. A: Both lungs from apices to bases included. Soft tissues included surrounding lung fields as appropriate. C: Inferior collimation distal to the diaphragm. Forward bending of the patient (or tilting of the light beam diaphragm) would allow collimation to parallel the anterior and posterior thoracic margins https://els-jbs-prod-cdn.jbs.elsevierhealth.com/cms/attachment/8ca21825-5c9e-4f8f-b05c-ac50bd7d4bad/gr1_lrg.jpg QUALITY CRITERIA: L RELATIVE POSITION Chin is not superimposing lungs Ribs posterior to the vertebral column are superimposed. Sternum is seen in profile Arms raised to demonstrate both lungs free from soft tissue superimposition. Superimposition of the posterior costophrenic recess Clear outline of diaphragm https://els-jbs-prod-cdn.jbs.elsevierhealth.com/cms/attachment/8ca21825-5c9e-4f8f-b05c-ac50bd7d4bad/gr1_lrg.jpg QUALITY CRITERIA: EXPOSURE L Contrast and density sufficient to visualise bone and soft tissue whilst able to appreciate lung markings The ribs and thoracic cage are seen only faintly over the heart https://els-jbs-prod-cdn.jbs.elsevierhealth.com/cms/attachment/8ca21825-5c9e-4f8f-b05c-ac50bd7d4bad/gr1_lrg.jpg ADDITIONAL/ALTERNATIVE AP erect Supine Expiration AP ERECT Pt sits upright – bring bed as close to 90 degrees as possible IR behind back approx. 3cm above shoulders. Midsagittal aligned to middle of IR Caudal angle 5-10° (CR perpendicular to sternum) Portrait/landscape detector depending on patient presentation https://www.auntminnie.com/index.aspx?sec=ser&sub=def&pag=dis&ItemID=129783 LORDOTIC : Clavicles superior to lung apices. Ribs projected horizontally CASE COURTESY OF DR IAN BICKLE, RADIOPAEDIA.ORG, RID: 77350 BASIC PROJECTIONS The following should be clearly shown: Apices in their entirety Superior lung region adjacent to the apices Clavicles located superior to the apices Sternal ends of the clavicles equidistant from the vertebral column Clavicles lying horizontally with their sternal ends overlapping only the first or second ribs Ribs distorted, with their anterior and posterior portions superimposed NOTE: The AP axial projection makes it possible to separate the apical and clavicular shadows without undue distortion of the apices. SUPINE Pt lying flat Midsagittal plane in centre of IR IR under back/trolley recess/bucky Centre beam to IR under bed/in bucky Caudal angle 5-10° (perpendicular to sternum) Note: reduced FFD ATHOLOGY COPD- Emphysema Pneumonia/infection Cancer Pleural effusion Pneumothorax Cardiomegaly Tubes, lines & clips Hiatus hernia COPD- EMPHYSEMA Chronic obstructive pulmonary disease Emphysema Chronic bronchitis Abnormal permanent enlargement of the airspaces and alveolar wall destruction 90% of all cases caused by smoking Symptoms: Dyspneoa, coughing, wheezing Findings on CXR: Lung hyperinflation, flattened hemidiaphragms, increase in size of retrosternal air space PNEUMONIA/INFECTION Alveolar air replaced with fluid Obscures lung markings Airspace opacification - Consolidation Patchy or extensive +/- atelectasis (collapse) Air bronchograms in progressive disease pneumonia pneumonia Endotracheal Tube (ETT) pneumonia Nasogastric Tube (NGT) ECG Wires PNEUMONIA- COVID-19 DAY 20 DAY 28 CANCER CXR is usually first investigation performed to investigate concerning symptoms CXR cannot determine invasive features of lesions CT used for complete staging Masses may be central or peripheral Central - Mostly squamous cell carcinoma and small call carcinoma Peripheral - Mostly adenocarcinoma and large cell carcinoma LUNG CANCER- HILAR MASS Right hilum abnormal Mediastinum widened due to lymph node enlargement Pleural effusion also present RIGHT UPPER LOBE COLLAPSE Dense opacity in right upper zone due to lobar collapse Highly likely that a mass is obstructing the right upper lobe bronchus PULMONARY METASTASES Secondary malignant tumours Originate from cancer in separate organ Single or multiple rounded nodules Peripheral distribution and usually bilateral PLEURAL EFFUSION Accumulation of fluid in the pleural space Erect position (supine and semi-erect radiographs mask findings) On an erect radiograph:  Small volume only seen on lateral CXR (posterior costo-phrenic recess)  >250ml - radiopaque meniscus at costo-phrenic angle(s)  Large volume - can create mass effect and collapse Causes: Infection | heart failure | malignancy | cirrhosis SMALL PLEURAL EFFUSION PA erect position - horizontal x-ray beam can visualise fluid levels and air-fluid interfaces PNEUMOTHORAX/ PTX Spontaneous | Traumatic | Tension Sudden, often severe onset chest pain and SOB Air in pleural space (Commonly apical on erect radiograph)  Lung edge visible with no lung markings peripheral  Collapse of lung (towards hilum) Closed or penetrating  Penetrating: rib # +/- subcutaneous emphysema Intercostal catheter (ICC) used to drain large volume SPONTANEOUS PNEUMOTHORAX Young Fit Male Tall and thin build TENSION PNEUMOTHORAX Air collection constantly enlarging Deviation of the trachea Compression of the contralateral side Mediastinal shift ICC inserted to drain air from pleural space INSPIRATION/EXPIRATION INSPIRATION/EXPIRATION WITH SHARP FILTER APPLIED CARDIAC FAILURE Congestive cardiac failure (CCF) | congestive heart failure (CHF) | heart failure (HF) Cardio-ventricular dysfunction - unable to pump blood sufficiently for body’s needs Right/Left ventricular failure Radiologic appearance- fluid in the lungs, cardiomegaly, pleural effusion CARDIOMEGALY CARDIOTHORACIC RATIO (CTR) HIATUS HERNIA Upper portion of the stomach herniates through the oesophageal hiatus. Air fluid level behind heart. Often incidental Pain | reflux | medication  TUBES, LINES & CLIPS/WIRES Tubes Central venous Clips/ wires  Endotracheal tube catheters (CVC)  Sternal sutures/wires (ETT)  Peripherally inserted  ECG clips and wires  Naso-gastric tube central catheter (PICC)  Pacemaker (NGT)  Internal jugular line  Intercostal catheter  Implantable ports (ICC) - chest drain  Pacemaker Nasogastric ECG Tube Leads Case courtesy of Dr Marcin Czarniecki, Radiopaedia.org, rID: 35185 The Abdomen Anatomy and Surface Anatomy Gastrointestinal Anatomy (Lower)  Stomach  Small Bowel  Large Bowel Small Bowel  Duodenum  Jejunum  Ileum Large Bowel  Caecum  Ascending Colon  Transverse Colon  Descending Colon  Sigmoid / Rectum …and the appendix!  Abdominal Surface Anatomy 1. Xiphoid 2. Inferior Costal Margin 3. Iliac Crest 4. ASIS 5. Greater Trochanter 6. Symphysis Pubis 7. Ischial Tuberosity Can you find the…  Stomach?  Duodenum?  Ascending Colon?  Descending Colon?  Hepatic Flexure?  Splenic Flexure? Region of the…  Transverse Colon?  Sigmoid Colon?  Cardiac Sphincter?  Appendix? Divisions of the Abdomen 84 Abdominal Organs Thoracic Organs Abdominal / Thoracic Interface: The Diaphragm Abdominal Organs: Gastrointestinal Abdominal Organs: Gastrointestinal Abdominal Organs: Gastrointestinal Abdominal Organs: Spleen Abdominal Organs: Liver Abdominal Organs: Genitourinary Abdominal Organs: Psoas Muscle The A.P. Supine Abdomen. Supine A.P. Abdomen Positioning Supine A.P. Abdomen Positioning The Supine A.P. Abdomen Critique. As much diaphragm shown as possible. Mid pubic symphysis included. Psoas muscle seen, if habitus allows. Nil rotation (pelvic symmetry). Wide window width. Markers to indicate side and position These criteria can be applied to virtually all plain radiographic projections of the abdomen. The P.A. Prone Abdomen. Prone P.A. Abdomen Positioning Position: Prone, true P.A. projection (crests equidistant from the image receptor). Angle: Straight tube (perpendicular to anatomy). CR: MSP, half-way between the lower costal margins and the iliac crests. Collimation: To the image receptor borders. IR: 35 x 43 Portrait. Marker: Inferolateral, reversed orientation. kVp: 75 kVp, +/-5. mAs: 30 mAs (estimate) or centre-cell AEC. F.F.D.: 100cm. Grid: Yes. Instruct: “Breathe out, and hold it out.” Breathing: Suspended expiration. Prone P.A. Abdomen Critique. As much diaphragm shown as possible. Mid pubic symphysis included. Psoas muscle seen, if habitus allows. Nil rotation (pelvic symmetry). Markers to indicate side and position. Wide window width. The Erect A.P. Abdomen. Erect A.P. Abdomen Positioning Position: Erect, true A.P. projection (crests equidistant from the image receptor). Angle: Straight tube (perpendicular to anatomy). CR: MSP, half-way between the lower costal margins and the iliac crests. Collimation: To the image receptor borders. IR: 35 x 43 Portrait. Marker: Inferolateral, normal orientation. kVp: 75 kVp, +/-5. mAs: 30 mAs (estimate) or centre-cell AEC. F.F.D.: 100cm. Grid: Yes. Instruct: “Breathe out, and hold it out.” Breathing: Suspended expiration. Erect A.P. Abdomen Critique  As much diaphragm shown as possible.  Mid pubic symphysis included.  Psoas muscle seen, if habitus allows.  Nil rotation (pelvic symmetry).  Wide window width.  Markers to indicate side and position.  Fluid levels, if evident, are clearly shown. These criteria can be applied to virtually all horizontal beam  L radiographic projections of the abdomen. Abdominal Radiographs: Erect vs. Supine  Left Lateral Decubitus Abdomen Positioning  Position: Left lateral, arms by side of the head, knees slightly flexed.  Angle: Horizontal beam (perpendicular to anatomy).  CR: Mid-sagittal plane, half-way between the lower costal margins and the iliac crests.  Collimation: To the image receptor borders.  IR: 35 x 43 Portrait (relative to patient orientation)  Marker: Inferolateral, normal / reversed orientation if A.P. / P.A., oriented to long axis. “Horizontal Beam” noted.  kVp: 75 kVp, +/-5.  mAs: 30 mAs (estimate).  F.F.D.: 100cm.  Grid: Yes – and be careful which one.  Instructions: “Breathe out, and hold it out.”  Breathing: Suspended expiration. Left Lateral Decubitus Abdomen Criteria  As much diaphragm shown as possible.  Mid pubic symphysis included.  Psoas muscle seen, if habitus allows.  Nil rotation (pelvic symmetry).  Markers to indicate side and position.  Wide window width.  Fluid levels, if evident, are clearly shown. L  As much as possible of the patient’s left side shown. Abdominal Radiographs: Why a left lateral decubitus? 108 Questions?  https://www.ajronline.org/doi/abs/10.2214/ajr.166.2.85 53937 https://www.thieme- connect.com/products/ejournals/html/10.1055/s-0033- 1350566 https://www.auntminnie.com/index.aspx?sec=ser&sub=d ef&pag=dis&ItemID=129783 https://bonexray.com/ https://www.asmirt.org/asmirt_core/wp- content/uploads/2464.pdf REFERENCES https://radiologykey.com/automatic-exposure-control/ http://incenter.medical.philips.com/doclib/enc/fetch/200 0/4504/577242/577261/577263/670329/670330/516 2433/452299103191_DigitalDiagnost_4_1_Specification.pdf%3fnodeid%3d10740235%26vernum%3d-2 https://ce4rt.com/positioning/radiographic-positioning-of- the-chest/ https://www.youtube.com/watch?v=obj3wpQfb8s https://medschool.co/tests/chest-xray/confirming- central-venous-access-position  Bontrager, K. L. (2005) Textbook of Radiographic Positioning and Related Anatomy. (6th edn.) St Louis: Mosby. Corne, J.; Carroll, M.; Brown, I. & Delany, D. (1997). Chest X- ray Made Easy. New York. Churchill Livingstone. Eisenberg, R. L. (2003) Comprehensive Radiographic Pathology (3rd edn.) St Louis: Mosby. Gyll,C. (1977).A handbook of Paediatric Radiography.(2nd edn ) Blackwell-Science:Asia. Hardy, M. & Boynes, S. (2003). Paediatric Radiography. REFERENCES Oxford. Blackwell Science. Lange, S. & Walsh, G. (1998). Radiology of Chest Disease. (2nd edn.). Stuttgart. Thieme. McQuillen-Martensen, K. (1996) Radiographic Critique. Philadelphia : W.B. Saunders. Sloane, R.M.; Gutierrez, F.R. & Fisher, A.J. (1999). Thoracic Imaging – A Practical Approach. New York. McGraw-Hill. Weir, J. & Abrahams, S. P. (2003) Imaging Atlas of Human Anatomy (3rd ed). London: Mosby.