Description of X-rays

1. Name
2. Age
3. Date
4. Institution
5. Bony alignment
6. Soft tissue alignment

X rays

Look at CXR for pneumothorax, lung edge away from bony chest wall. Air in the soft

tissues of the chest wall indicates surgical emphysema. Look for the associated rib

fractures! A patient with multiple rib fractures (x6) on one side or 2 or more ribs

fractured in 2 or more places has a flail chest. These patients are at high risk for

respiratory failure because of the splinting associated with the pain of breathing and the

ventilatory perfusion mismatch underlying lung contusions.

may be a spontaneous pneumothorax. Usually in spontaneous pneumothorax there is

evidence on the CXR of underlying lung disease such as bullae or hyperinflated lung

fields. Air fluid level on chest X ray usually means haemo-pneumothorax which usually

occurs after trauma. This should be distinguishable from a pleural effusion which

usually has a meniscus at the upper border of the fluid.

A tension pneumothorax, though not a common radiological finding is often present in

the exams and the discussion of its emergency management is a must by the candidate.

This includes the passage of a wide-bore cannula in the 2nd intercostal space, mid

clavicular line of the affected side with an expected gush of air.

Radio opaque line on CXR may indicate a CVP Line. Similarly a pacemaker may be

visible on the CXR. If a blood vessel is being filled with contrast material in proximity to

a catheter then it usually indicates an angiogram. Inspect to see if veins (which are larger)
are being filled with contrast also as this may mean that an arterio-venous fistula is being

demonstrated. The student should be familiar with the performance of an angiogram,

realizing that the majority are performed after gaining access through the femoral artery.

They should be familiar with the appearance of a pseudo-aneurysm and should be able to

discuss the complications of an angiogram.

Air in mediastinum indicatespneumo-mediastinum which may indicate injury to an air

containing viscusegoesophagus or trachea post blunt or penetrating trauma or

iatrogenically , post oesophagoscopy. A patient with a pneumopericardium after

penetrating thoracic injury requires exploration because of the possibility of a cardiac

tamponade. This patient may not have all the features of Becks triad.

Gastrointestinal ,Genitourinary tract

Naso- gastric tube used therapeutically for GI decompression post operatively, and as

simple tube drain for tissue flaps post op. It can also be used to construct a double lumen

sump drain and for naso-gastric feeding or as a jejunostomy tube for feeding. As a

diagnostic tool it is used to assay gastric acid secretions and to determine the presence of

bile in duodenal secretions .

Rigid bronchoscope as side holes also used to remove aspirated airway foreign bodies

Rigid Oesophagoscope no side holes also used to perform injection sclerotherapy for

oesophagealvarices and to remove foreign bodies eg a coin. It is usually used under

general anaesthesia and there is the risk of oesophageal perforation during its use. At this

point a barium swallow showing an irregular stricture with shouldering in keeping with

oesophageal carcinoma or a dilated oesophagus tapering down to a rat tail smooth

stricture in keeping with achalasia may be introduced. The clinical differences between
the two include the absence of anorexia and relative absence of significant weight loss in

achalasia. This is in addition to the sequence of dysphagia.

Sengstaken Blakemore tube (red) has 3 lumens, and two balloons, a stomach and a

longer oesophageal balloon with the third lumen for gastric aspiration.

Mousseau-Barbin tube is palliative treatment for oesophageal malignant stricture. It is

almost now never used because of the poor palliation which it offers with the risk of

erosion of the oesophagus and aspiration amongst others. Most patients with advanced

cancer of the oesophagus are palliated with a combination of chemotherapy, radiotherapy

and the placement of self expanding metallic stents.

In passing the Mousseau-Barbin tube, the stomach has to be opened through a small

incision and the thin leading portion of the tube grasped and the tube pulled through the

stricture until the wide funneled portion impacts at the stricture site.

Rigid sigmoidoscope,usual length 25 cms, anal canal length 3-4cms, length of rectun

12cms,so one is able to inspect app 10 cms of sigmoid colon with this length instrument

and detect the majority of distal colorectal cancers. With the general right sided shift in

colonic cancers noted, it is an in adequate investigation for bowel evaluation. It is

however invaluable in evaluation the rectum in a patient who has had a double contrast

barium enema as the Ba enema can miss up to 20 % of rectal lesions.

Flexible sigmoidoscope length 60cms and evaluates up to the splenic flexure in the

average adult.

Colonoscopy longer can visualize to caecum and sometimes see terminal ileum in

Crohns disease. It requires a trained operator and there is the risk of bowel perforation

occurring 1/1000. Its performance is contraindicated in the patient with acute

diverticulitis. These are endoscopic procedures and can diagnose colorectal cancers

ulcerative colitis ,Crohnsdisease,polyps which may be benign adenomatous if

pedunculated or often malignant if sessile, villous and large. Other type of polyps

include inflammatory polyps in ulcerative colitis a pre malignant condition

,hamartomatous or juevenile polyps (benign).

Familial adenomatous , polyposis syndrome ,is a pre malignant hereditary mendalian

autosomal dominant transmission .

Other polyposis syndromes includes Gardners syndrome(dermoid cysts ,osteomas of the

mandible and abdominal wall desmoid tumors) and Lynchs syndrome (heriditary non-

polyposis colon cancer). These patients cancer started in a polyp (hence the name is a

misnomer) and in addition to the familiar tendencies, the cancers are right sided in

distribution and occur before age 45.

Abdominal Xrays: dilated bowel and air fluid levels in a step ladder fashion indicate

bowel obstruction. The number of air fluid levels is proportionate to the degree of small

bowel obstruction. Gas shadows in the jejunum pass from ante-mesenteric to mesenteric

border and are called valvulaeconniventes. Dilated small bowel is usually

centrallyplaced while large bowel is on the periphery. TheX ray appearance cannot make

the diagnosis of mechanical intestinal obstruction as the identical appearance maybe seen

in paralytic ileus or gastroenteritis especially in children. The site and cause of small

bowel obstruction can be demonstrated with an enteroclysis (or small bowel enema).

This involves injection of barium under pressure in a nasogastric tube which is usually

sited in the proximal small bowel.

Large bowel haustral folds unlike valvulaeconniventes are not shown as a line

completely across the bowel but are spaced irregularly. and indentations are not opposite

each other. If the ileocaecal valve is competent in the presence of complete large bowel

obstruction the patient has a closed loop obstruction and is at increase risk of perforation

which usually occurs at the level of the caecum. A closed loop obstruction is also present

in patients with sigmoid volvulus which has a typical appearance of a single large loop

of bowel in the shape of omega extending from the LIF to the RUQ. Once there is no

peritonitis or altered blood on DRE the majority of patients (80%) can be decompressed

with a rigid proctosigmoidoscopy and flatus tube.

A radio-opaque catheter on a plain abdominal film may be a feeding jejunostomy or a

peritoneal dialysis catheter. The tip of the peritoneal dialysis catheter usually sits in the

pelvis.

A double contrast barium enema can show the typical apple core lesions of a colonic

carcinoma or multiple filling defects of colonic polyps. The presence of diverticulosis is

shown by multiple barium filled pockets especially in the sigmoid colon.

A T-tube is use after exploration of the common bile duct and in addition to

decompression of the biliary tree immediately post-op, it facilitates a cholangiogram

about 7 to 10 days after surgery. Once there is no retained stones it can be removed at this

time as there is the formation of a fibrous tract along its path. The T-tube tract can be

cannulated under fluoroscopic guidance to facilitate the removal of retained stones from

the common bile duct.

A colostomy bag is usually present to lead to the discussion of the types of colostomy

which maybe temporary of permanent or constructed from the loop of bowel, end or both

ends (double barrel colostomy).

Cardiothoracic/Vascular X-rays
1 = PVD
2 = GSW: Pseudoaneurysm in popliteal artery
3 = Greenfield Filter
4/5 = Solitary Right Lung
6 = A/F Level Right Lung: Abscess
7 = Pneumothorax
8 = Lung Collpase
9 = Fractured Ribs and Surgical Emphysema
10 = Pleural Effusion

Chest X- rays:
Be able to identify
Haemothorax air fluid level, cannot differentiate from hydrothorax or pleural
effusion by X-ray.
Pneumothorax look for the disappearance of the lung markings in the periphery
Tension pneumothorax- deviated trachea, deviated mediastinum to opposite side
and collapsed lung. Immediate management 14/16G branula in 2ICS followed
by chest tube. Thoracotomy if immediately >1000-1500 ml, or if CVS unstable or
if >200-300ml/hr for three consecutive hours.
Apical/Basal chest tube
Coin Lesions
Surgical Emphysema

Angiogram:
Recognise a point of obstruction
Recognise the presence of a pseudoaneurysm
*MUST KNOW ARTERIES and MENTION THEM!!!*
In the lower limb- Femoral artery divides below the ?inguinal ligament?to give
profundafemoris and superficial femoral a. The superficial femoral a. becomes the
popliteal a. which divides below the popliteal fossa into the ant. Tibial a. and post.
Tibial a. The post tibial a. gives off the peroneal a.
In the upper limb- The axillary a. becomes the brachial a in the upper arm. The
brachial a gives of the profundaa at its origin. Below the elbow the brachial
divides into the radial and ulnar a. The ulnar a gives of the common interosseus
near its origin which further divides into ant and post interosseus a.
If a blood vessel is being filled with contrast material in proximity to a catheter
then it usually indicates an angiogram. Inspect to see if veins (which are larger)
are being filled with contrast also as this may mean that an arterio-venous fistula
is being demonstrated.
Types of angiograms
o Digital Subtraction Angiogram (DSA)
o CT Angiogram
o MRI Angiogram
 Types of aneurysms
o Saccular: spherical in shape and involve only a portion of the vessel wall;
they vary in size from 5 to 20 cm in diameter, and are often filled, either
partially or fully, by thrombus
o Fusiform: "spindle-shaped" aneurysms; are variable in both their diameter
and length; their diameters can extend up to 20 cm. They often involve
large portions of the ascending and transverse aortic arch, the abdominal
aorta, or less frequently the iliac arteries.
1 = PVD

X-ray description: Digital subtraction angiogram (DSA) There is complete

occlusion/ cut-off sign of the superficial femoralartery . Poor/few collateral
vessels seen at tibia/fibula
Can be acute (b/c has few collaterals) or chronic (atherosclerotic plaques;
presenting with claudication)
Can be caused by
o Dislocation
o Embolus/clot
o Trauma
Direct blunt trauma
Gun shot wound
Stab wound
Causes of Acute limb ischaemia
o Embolism (Tx: embolectomyw/ ?Faugertys? Catheter)
o Trauma (+ extravasation of blood)
Need distal run off for reconstruction b/c need something to connect to
2 = GSW: Pseudoaneurysm in popliteal artery
 Traumatic aneurysms are new trauma aneurysm and are always
FALSE/PSEUDOANEURYSM
X-ray description: CT angigram of a pseudoaneurysm to the popliteal artery
seconday to trauma, likely gun shot wound and extravasation of contrast into
saccularoutpouching

Pic 395-396
Femoral angiogram showing Traumatic arterio-venous fistula with
pseudoaneurysm. There is a non-anatomical defect in the distal third of the
superficial femoral artery and associated false aneurysm due to extravasation of
contrast from the artery into the femoral vein because the wall has been breached.
May be iatrogenic or secondary to trauma.
Catheter may be inserted in contralateral femoral artery and threaded across or
directly into the affected ipsilateral femoral or via translumbaraortogram.
 Pic 410-411
Subclavian angiogram Bullet is seen, Extravasation of contrast seen with false aneurysm
of axillary artery. Post-traumatic false aneurysm of axillary artery.

3 = Greenfield Filter

X-ray description: Green field filter at the level below L1/L2 below the level
where renal veins join (to prevent obstruction of the renal veins)
Used to prevent FATAL pulmonary embolism i.e. SaDDLE EMBOLISM (smaller
clots may pass through)
Indication: Pt w/ PROVEN PREVIOUS PULMONARY EMBOLISM
Fill in the following!!!:
DVT,
o Tx
Coumadin
Heparin
o Clotting Factors
Role of Vitamin K
Intrinsic and Extrinsic PAthway
4/5 = Solitary Lesion in Right Lung

X-ray description: radiopaque mass in the R upper/middle lobe, prominent

bronchi, prominent bronchovesicular markings in right base (b/c mass above
causing build up below) wire in sternum (suggest a biopsy in a recurrent lesion)
If seen ask for a lateral to determine if in anterior, posterior, or lateral
compartment
Mediastinum is divided into 3 parts
o Anterior
Thymus
Thyroid
Parathyroid
Pathology: teratoma
o Posterior
Sympathetic chain w/ nerves
Pathology: Neurofibroma or Schwanoma
o Middle
LN
Vessels
Solitary lesions ddx:
o Solitary unilateral area of opacity: lung cancer, abscess, TB , IV drug users
(Staph aureus), fungal infection of immunocompromised , granulomatosis
o Unilateral radio-luscent zone bullae, emphysema, foreign body,
o Entire lung - pneumonectomy
Ct Scan to delineate mass w/ CT guided bx

6 = A/F Level Right Lung: Abscess

 X-ray showing an air fluid level therefore suggests a cavity therefore if a straight
line is seen on X-ray think abscess
Signs/Symptoms
o Fever
o Sputum
o Sepsis
o Fatigue
Investigations
o CXR: Air fluid level
o CT Scan to define position and differentiate from empyema
o Bronchoscopy (look for cancer/culture)
Tx
o Antibiotics
o Bronchoscopy for culture and toilet
o +/- Sx
Indications
Underlying cancer/tumor
Refractory to antibiotics
Options
Lobectomy of lobe with abscess
Tube drainage
Middle lobe syndrome = recurrent middle lobe pneumonias due to EXTRINSIC
bronchial obstruction

7 = Pneumothorax

X-ray Description:
o L sided pneumothorax (air trapped in the pleural space).
o Blunting of costophrenic angle haemothorax
o Therefore haemopneumothorax
 Pic 319- 320
Chest xray showing hyper-inflated lung fields with right pneumothorax. Likely
spontaneous pneumothorax (visceral pleura ruptures but there no external
trauma). Can be primary or secondary (underlying lung pathology). Causes
include- Emphysema, asthma, endometriosis, tuberculosis etc.
Pneumothorax presentation:
o Tachypnea
o Tachycardia
o Chest pain
Pneumothorax rx:
o Resuscitate patient
o Oxygenate
o Insert chest tube
Indications for chest tube placement:
o pneumothorax > 20 % ( ie crosses at least 2 ribs or lung markings > 1 cm
away from lateral chest wall)
o symptomatic patient regardless of size of pneumothorax
o pneumothorax due to trauma
o haemothorax or haemopneumothorax
o chylothorax
o empyema
Reasons why a chest tube may fail to drain
o Tube not in place
o Tube not secured properly
 o Occlusion of tube due to a clot
o Kinking of the chest tube
o Due to a bronchopleural fistula(due to penetrating trauma)
o Chest tube not connected adequately to underwater seal

Pic 316
Chest xray showing Left tension pneumothorax ,haemothorax with mediastinal
shift, and lung collapse. Trachea and heart deviated to the right.
This xray should never have been taken b/c with Tension pneumothorax an X-ray
should NOT be done, patient can die waiting to get one, treat immediately
Tension pneumothorax:
o Buildup of pressure within the hemithorax (air goes out of lung but cant
be drawn back in) to the extent that the lung is completely collapsed,
diaphragm flattened, venous return compromised. Patients on mechanical
ventilation at greatest risk.
Treatment is to insert a large bore sheathed needle eg) 16 G iv cannula in the 2
ICS in MCL. Following relief of the tension pneumothorax a basal thoracostomy
tube with under water seal must be sited in the 5 ,6 or 7th LICS anterior to MAL in
order to avoid long thoracic nerve ( which supplies Serratus anterior causes
winging scapula if damaged).
Tension pneumothorax: surgical emergency
o Presentationincludes:
Nasal flaring
Dyspnea
Cyanosis
Distended neck veins
o Signs
Distended neck veins
Tracheal deviation
Tachycardia
Hyper-resonance of the chest due to air
Decreased breath sounds
Normal heart sounds
Decreased chest wall expansion
Increased percussion note on affected side
 Pic 306
Chest X-ray of right hemothorax showing heterogenous lesion in right upper lobe; hilar
lymphadenopathy.Possibly due to bronchogenic cancer. May present with dyspnoea,
chest pain, Horners syndrome or symptoms of paraneoplasticsyndrome : SIADH,
Proximal myopathy, HPOA, Myasthenia gravis like syndrome.

Pic
384-386
Massive haemopneumothorax with chest tube in situ

8 = Lung Collpase

X-ray description
o AP X-ray (therefore cannot comment on mediastinum re: cardiomegaly)
o Collapsed lung and air occupying space = pneumothorax
 o Haemothorax seen: bunting of costophrenic anglehaemopneumothorax
o The film is rotates, therefore cannot comment on medistinal shift
o Tube placed but not working properly (NB: Can induce a tension
pneumothorax b/c of problem w/ tube)
NB: Lung NOT hyperinflated b/c otherwise occupied by pneumothorax and
collapsed lung and this is acute

9 = Fractured Ribs and Surgical Emphysema

Air in the soft tissues of the chest wall indicates surgical emphysema. Look for
the associated rib fractures! COMMON CAUSE
Air in subcutaneous tissue outside of chest; air in b/w pectoralis major fibres,
trasverese lines towards apex of humerus
X-ray looks DIRTY

10 = Pleural Effusion

Pleural effusion is excess fluid that accumulates in the pleural cavity, the fluid-
filled space that surrounds the lungs. Excessive amounts of such fluid can impair
breathing by limiting the expansion of the lungs during respiration.
X-ray description: Total opacification of entire L field = COMPLETE WHITE
OUT of LEFT HEMITHORAX. Film is rotated but gives the impression that the
trachea is deviated to the right
Pleural effusion secondary to malignant effusions due to
o Primary malignancy: bronchogenic carcinoma
o Secondary Metastases
Breast
 GI
Colon cancer
Prostate cancer
Bladder cancer
Neuroblastoma
Sarcoma
Ovarian
NB: can also be see white out in complete lobar pneumonia
Lung is HYPERINFLATED on right side to compensate for L side, noted by
increased rib spacing on the R side
Pleural Effusion vs Consolidation
Hx: May be asymptomatic Hx:
Trachea deviated to opposite side Trachea Central
Decreased Tactile Vocal Fremitus Increased Tactile Vocal Fremitus
Decreased BS Bronchial BS
Dull Percussion Dull Percussion
Transudative (bilateral ONLY) vs Exudative: Lights Criteria
o Definitions of the terms "transudate" and "exudate" are the source of much
confusion. Briefly, transudate is produced through pressure filtration
without capillary injury while exudate is "inflammatory fluid" leaking
between cells.
o Transudative pleural effusions are defined as effusions that are caused by
systemic factors that alter the pleural equilibrium, or Starling forces. The
components of the Starling forceshydrostatic pressure, permeability,
oncotic pressure (effective pressure due to the composition of the pleural
fluid and blood)are altered in many diseases, e.g., left ventricular failure,
renal failure, hepatic failure, and cirrhosis. Exudative pleural effusions, by
contrast, are caused by alterations in local factors that influence the
formation and absorption of pleural fluid (e.g., bacterial pneumonia,
cancer, pulmonary embolism, and viral infection)

o An accurate diagnosis of the cause of the effusion, transudate versus

exudate, relies on a comparison of the chemistries in the pleural fluid to
those in the blood, using Light's criteria. According to Light's criteria
(Light, et al. 1972), a pleural effusion is likely exudative if at least one of
the following exists

The ratio of pleural fluid protein to serum protein is greater than

0.5

The ratio of pleural fluid LDH and serum LDH is greater than 0.6

Pleural LDH is greater than 200

 Pleural fluid LDH is greater than 0.6 or times the normal upper
limit for serum. Different laboratories have different values for the
upper limit of serum LDH, but examples include 200and 300IU/l.

o Although Light's criteria are relatively accurate, twenty-five percent of

patients with transudative pleural effusions are mistakenly identified by
Light's criteria as having exudative pleural effusions. Therefore, if a
patient identified by Light's criteria as having an exudative pleural
effusion appears clinically to have a condition that usually produces
transudative effusions, additional testing is needed. In such cases
albuminlevels in blood and pleural fluid are measured. If the difference
between the albumin level in the blood and the pleural fluid is greater than
1.2 g/dL (12 g/L), this suggests that the patient has a transudative pleural
effusion. However, pleural fluid testing is not perfect, and the final
decision about whether a fluid is a transudate or an exudate is based not on
chemical analysis of the fluid, but on accurate diagnosis of the disease that
produces the fluid.

o The traditional definitions of transudate as a pleural effusion due to

systemic factors and an exudate as a pleural effusion due to local factors
have been used since 1940 or earlier (Light et al., 1972). Previous to
Light's landmark study, which was based on work by Chandrasekhar,
investigators unsuccessfully attempted to use other criteria, such as
specific gravity, pH, and protein content of the fluid, to differentiate
between transudates and exudates. Light's criteria are highly statistically
sensitive for exudates (although not very statistically specific). More
recent studies have examined other characteristics of pleural fluid that may
help to determine whether the process producing the effusion is local
(exudate) or systemic (transudate). The chart at right illustrates some of
the results of these more recent studies. However, it should be borne in
mind that Light's criteria are still the most widely used criteria.

o The Rational Clinical Examination Series review found that bilateral

effusions, symmetric and asymmetric, are the most common distribution
in heart failure (60% of effusions in heart failure will be bilateral). When
there is asymmetry in heart failure-associated pleural effusions (either
unilateral or one side larger than the other), the right side is usually more
involved than the left

Causes
o Transudative
The most common causes of transudative pleural effusions in the
United States are left ventricular failure, and cirrhosis (causing
hepatic hydrothorax),nephrotic syndrome leading to increased loss
of albumin and resultant hypoalbuminemia and thus reducing
colloid osmotic pressure is another less common cause. Pulmonary
 embolisms were once thought to be transudative but have been
recently shown to be exudative
o Exudative

Pleural effusion Chest x-ray of a pleural effusion. The arrow A shows fluid layering in the
right pleural cavity. The B arrow shows the normal width of the lung in the cavity
Once identified as exudative, additional evaluation is needed to
determine the cause of the excess fluid, and pleural fluid amylase,
glucose, pH and cell counts are obtained.

Pleural fluid amylase is elevated in cases of esophageal rupture,

pancreatic pleural effusion, or cancer.

Glucose is decreased with cancer, bacterial infections, or

rheumatoid pleuritis.

Pleural fluid pH is low in empyema (<7.2) and may be low in

cancer.

If cancer is suspected, the pleural fluid is sent for cytology. If

cytology is negative, and cancer is still suspected, either a
thoracoscopy, or needle biopsy[12] of the pleura may be performed.

The fluid is also sent for Gram staining and culture, and, if
suspicious for tuberculosis, examination for TB markers
(adenosine deaminase> 45 IU/L, interferon gamma> 140 pg/mL,
or positive polymerase chain reaction (PCR) for tuberculous
DNA).

The most common causes of exudative pleural effusions are

bacterial pneumonia, cancer (with lung cancer, breast cancer, and
lymphoma causing approximately 75% of all malignant pleural
effusions), viral infection, and pulmonary embolism.

o Other/ungrouped
 Other causes of pleural effusion include tuberculosis (though
pleural fluid smears are rarely positive for AFB, this is the most
common cause of pleural effusion in some developing countries),
autoimmune disease such as systemic lupus erythematosus,
bleeding (often due to chest trauma), chylothorax (most commonly
caused by trauma), and accidental infusion of fluids.

Less common causes include esophageal rupture or pancreatic

disease, intra-abdominal abscess, rheumatoid arthritis, asbestos
pleural effusion, Meigs syndrome (ascites and pleural effusion due
to a benign ovarian tumor), and ovarian hyperstimulation
syndrome.

Pleural effusions may also occur through medical/surgical

interventions, including the use of medications (pleural fluid is
usually eosinophilic), coronary artery bypass surgery, abdominal
surgery, endoscopic varicealsclerotherapy, radiation therapy, liver
or lung transplantation, and intra- or extravascular insertion of
central lines.

Treatment depends on whether pt is symptomatic or asymptomatic. If fluid is

removed too quickly shift of the mediastinum can occur kinking of the IVC
Haemorrhage shock therefore remove 50cc over 2hrs

CT chest can be done to determine if a tumor is present

Pic 317
Right pleural effusion.
 Pic 321-322
Chest xray showing multiple coin lesion = lung
mestastases. Note military Tb deposits are same size on CXR while lung mets are
of variable size.

FLAIL CHEST

Rib fractures in 2 or more places in 3 or more consecutive ribs

Results in paradoxical movement of the flail segment in relation to the rest of the
anterior chest wall with respiration

The paradoxical movement causes pulmonary contusion

Due to pulmonary contusion, there is a V/Q mismatch and therefore its difficult to
ventilate the lung adequately.

This causes hypoxia

Indications for chest tube insertion with flail chest:

o Patient progressivelt gets worse

o Patient mechanically ventilated risk of creating a tension pneumothorax

o Increases oxygenation as it allows the lung to expand easier

Gastrointestinal X-rays

1= Pneumoperitoneum
2 = Intestinal Obstruction: Supine
3 = Intestinal Obstruction: Erect
4 = Lateral Decubitus
5 = Barium Swallow: Cancer of Oesophagus
6 = Intussception
7 = Intussception
8 = Barium Enema: Diverticula
9 = Barium Enema: Apple Core Lesion CA
10 = Barium Meal: Gastric Outlet Obstruction
11 = Barium Meal: Gastric Outlet Obstruction
12 = Barium Meal: Hypertrophic Pyloric Stenosis
13 = T-tube Cholangiogram

Be able to identify
Gall stones vs Renal stones differentiate by a lateral film where gall stones are
anterior and renal stones posterior.
Intestinal obstruction identify distended loops of bowel and tell if large or small
on supine film. On erect film, see air fluid levels. In partial obstruction air in the
rectum
Sigmoid volvulus- Omega sign
Pancreatitis- sentinel loop, colon cut off sign
Pneumpoeritoneum Due to perforated viscus, subhepatic abscess with gas
forming organisms, or due to laparotomy/laparoscopy.

NB: Plain Abdominal X-rays are done if obstruction or pneumoperitoneum is suspected

and RARELY kidney disease (Normally use KUB)
Barium Swallow = Oesophagus and GE Junction
Barium Meal = Stomach
Barium Follow Through = SI
Barium Enema = LI

Normal size/diameter of intestines 3, 6, 9cm rule. 3 small intestines, 6 large

intestines and 9 caecum.
#1: Pneumoperitoneum

Pic 327

Note this X-ray is inadequate b/c apices not seen

FREE AIR under the right hemidiaphragm (Not normally seen)
NB: When looking at a CXR ALWAYS R/O problem in abdomen,
pneumoritoneum
CXR is done b/c abdominal Xray does not always show the diaphragm
Pneumoperitoneum refers to air in the peritoneal cavity (air under diaphragm on
xray) but outside of the lumen of the bowel.
Most common cause is laparoscopic surgery (air insufflation via Veress needle)
Riglers sign aka double wall sign. Seen on xray of abdo when air is present
on both sides of the intestine i.e. luminal, peritoneal side of bowel wall. The
walls of bowel seen clearly with lines on each side visible. In normal scans you
can hardly make out intestines.
Significant on right side because normally the liver occupies the space and on the
left side a gastric bubble, splenic flexure and small bowel may give the same
impression and therefore can not be certain that it is free air under the diaphragm
Bilateral pneumoperitoneum
o Perforated ulcer
 o Ruptured appendix
o Post laparoscopy
If no pneumoperitoneum but perforation is suspected:
o Gastrograffin
o Endoscope
o Air in NG tube
So why does a patient with pneumoperitoneum present with shock:
o Peritonitis due to bile/blood contents
o Vomiting therefore dehydrated
o Sepsis due to bacteria
Causes include :
o Perforated hollow viscus
Perforated peptic ulcer/duodenal ulcer
Signs of perforation
o Hypovolemia erosion of gastroduodenal artery
(branch of Common hepatic artery)
o Bleeding
o Severe pain
o Kehrs sign (shoulder tip pain) referred pain
Aetiology for perf ulcers
o Drugs
NSAIDS Diclofenac, Ibuprofen,
Acetylsalycilic acid
Steroids
Cocaine/marijuana
o H. Pylori
o What is the cause of Curling's ulcer and Cushing's
ulcer? (Where do these ulcers occur?)
o Curling's: burns --> decreased plasma volume -->
sloughing of gastric mucosa
o Cushing's ulcer --> brain injury raised ICP --> vagal
overstimulation -->dysregulated acid secretion
o (stomach)
o Zollinger Ellison syndrome (non beta cell
pancreatic tumor secreting gastrin stimulates
release of acid in stomach). Found in pancreas,
stomach and duodenum. Main complaint is
diarrhoea due to large volumes of acid secreted into
small intestine.
Management
 o Resuscitate A (Oxygen) BCs (2 large bore IV
cannulae, 4L/24hrs, Grp and cross match 2
units of blood)
o Catheterise
o NG Tube
o Antibiotics 3rd generation cephalosporin and
metronidazole
o PPI Omeprazole
o Analgesics Morphine
Surgery options
o Omental patch
o Recurrent perforated ulcers (2nd episode):
Selective vagotomy with pyroloplasty
Partial gastrectomy
Antrectomy - has the gastrin producing
cells therefore acid
Perforated/Ruptured diverticulum
Perforated/Ruptured Appendix
Features of a ruptured appendix
o Pneumoperitoneum
o Intestinal obstruction (small bowel) ileus
o Fat straddling
o Loss of Psoas shadow
o Air around appendix
o fecolith
Inflammatory Bowel Disease
Crohns
UC

Ruptured inflammatory bowel disease (e.g. megacolon)

o Penetrating abdominal wall injury

o Post laparotomy
o Post laparoscopy

o Bowel obstruction

o Necrotisingenterocolitis

Pneumatosis coli (presence of thin-walled, gas-containing cysts in

the wall of the intestines)

o Bowel Cancer
 o Ischemic bowel

o Steroids

o Breakdown of a surgical anastomosis

o Bowel injury after endoscopy

o Peritoneal dialysis

o Vaginal insufflation (air enters via the fallopian tubes, e.g. water-skiing,
oral sex)

o Colonic or peritoneal infection

o From chest (e.g. bronchopleuralfistula)

o Non-invasive PAP (positive airway pressure) can force air down

duodenum as well as down trachea.

DDx
o Subphrenic abscess due to gas forming organisms

o Linearatelectasis at the base of the lungs can simulate free air under the
diaphragm on a chest X-ray.

o Chilaiditis phenomenon, a congenital disorder which

mimickspneumoperitoneum. Bowel is actually under the right hemi-
diaphragm. i.e. bowel interposed between diaphragm and liver
Clinical Presentation
o The clinical presentation depends on the cause of the pneumoperitoneum.
Benign causes of pneumoperitoneum are typically asymptomatic,
but the patient may have vague abdominal pain.
Pneumoperitoneum symptoms resulting from perforated abdominal
viscus depend on the subsequent development of peritonitis. Signs
and symptoms of various causes of perforation may be peritoneal
signs such as a rigid, tender abdomen, absent bowel sounds, severe
epigastric pain or hypovolaemic shock.
o Peritonitis
Causes of peritonitis
Bile
Bowel contents
Blood
 o Hypovolaemic chock
o Vomiting dehydration
Management
o IV access 2 large bore IVs, Grp and cross match blood
o Fluid resuscitation
Lactated ringers to replace K and N/S; regardless of choice will
ensure to correct for electrolyte abnormalities
o Bloods
CBC
Increased WCC esp immature Neutrophils L shift
ABGs
Amylase and lipase
U&E
Electrolyte imbalance
o Depends on where is obstructed
o NG Tube
Decompress Paralytic ileus that may form as a result of peritonitis
Preop for surgery to prevent aspiration
o Analgesia (type will depend on pt
o Foleys Cather (to monitor resuscitation)
o Prophylactic antibiotics
o PPI infusion
o Informed consent
o OT
Types of peritonitis
o Localized
o Generalized
Bowel Obstruction:
Small Bowel
o Dilated bowel and air fluid levels in a step ladder fashion indicate bowel
obstruction.
o The number of air fluid levels is proportionate to the degree of small
bowel obstruction.
o Gas shadows in the jejunum pass from ante-mesenteric to mesenteric
border and are called valvulaeconniventes.
o Dilated small bowel is usually centrallyplaced while large bowel is on the
periphery.
o TheX ray appearance cannot make the diagnosis of mechanical intestinal
obstruction as the identical appearance maybe seen in paralytic ileus or
gastroenteritis especially in children.
o The site and cause of small bowel obstruction can be demonstrated with an
enteroclysis (or small bowel enema). This involves injection of barium
under pressure in a nasogastric tube which is usually sited in the proximal
small bowel.
o Faeculent smell: smells like faeces but is due to bacterial digestion of
food. Represents distal SBO
Causes of SBO
o Adhesions previous surgery, blood, perforation, scarring from surgery
Why would we do surgery even with adhesions as cause of SBO
Constant pain
Tachycardia
No bowel sounds or high pitched bowel sounds
Increase in NG fluids, fecolith or blood
Rigid abdo, guarding and tenderness
o Hernia
Types: Commonest to least common (external hernias)
Inguinal: common content is small bowel
Incisional
Paraumbilical: common content is omentum
Divarication of rectus sheath
Femoral
Umbilical
Spegelian found at junction between semilunaris and
rectus
Strangulated hernias gangrenous and perforation risks
Internal hernia protrudes through mesentery from previous repair
o Meckels Diverticulum: 2%, 2cm, 2feet from ileo-caecal valve
o Ischemia bowel paper thin therefore easily ruptures, bacteria
translocated into peritoneum causing gangrene.
Signs of healthy bowel
 Peritoneal sheen
Pink
Peristalsis
Mesentery pulsation
o Tumors that cause SBO Benign and malignant
Harmatomas
Lymphomas
Polyps
o Other causes of SBO
Intussuseption
Gallstone ileus
Crohns - causes strictures (ischemia and inflammation)
Parasites Ascarislumbricoides
If you think its obstruction and x rays dont show then do gastrograffin
 Large bowel:
o Haustral folds unlike valvulaeconniventes are not shown as a line
completely across the bowel but are spaced irregularly. and indentations
are not opposite each other.
o If the ileocaecal valve is competent in the presence of complete large
bowel obstruction the patient has a closed loop obstruction and is at
increase risk of perforation which usually occurs at the level of the
caecum.
o A closed loop obstruction is also present in patients with sigmoid volvulus
which has a typical appearance of a single large loop of bowel in the shape
of omega extending from the LIF to the RUQ. Once there is no peritonitis
or altered blood on DRE the majority of patients (80%) can be
decompressed with a rigid proctosigmoidoscopy and flatus tube.
Types of scopes
Flexible sigmoidoscope 60cm
Rigid sigmoidoscope 25cm
Large bowel is 5ft (60cm)
o Coffee bean sign
o Common in elderly due to long mesentery
o Causes (most common to least common)
Colorectal carcinoma (left side)
PR bleed
Tenesmus
Change on bowel habit
Sigmoid Volvulus
Diverticular diz
Faecal impaction
Pseudo obstruction is a functional obstruction and causes LBO and
fecal impaction. To dx use gastrograffin uninterrupted flow of
contrast (will go all the way to caecum and anus with no
obstruction evident).
Causes
o Trauma
o Sepsis
o Drugs phenothiazines, amytryptilline
o Hypokalemia
o Hypothyroidism
o hypercalcemia
o Presentation
Abdominal distension
Abdom Pain
Constipation
Vomiting
 Pseudoobstruction
Classification
o Dynamic/Mechanical vsAdynamic Obstruction or High vs Low
Obstruction
Adynamic
Paralytic ileus
o Also called pseudo-obstruction, is one of the major
causes of intestinal obstruction in infants and
children.
o Causes may include:

Chemical, electrolyte, or mineral

disturbances (such as decreased potassium
levels)

Complications of intra-abdominal surgery

Decreased blood supply to the abdominal

area (mesenteric artery ischemia)

Injury to the abdominal blood supply

Intra-abdominal infection

Kidney or lung disease

Use of certain medications, especially

narcotics

Dynamic/Mechanical
Adhesions
Hernia

Intussusception

Tumors blocking the intestines

Volvulus (twisted intestine)

Foreign bodies (ingested materials that obstruct the

intestines)

Impacted feces (stool)

 Management
o LBO
Resuscitate
NG Tube to decompress
Rigid sigmoidoscope can decompress too
Surgery resection of sigmoid colon
o Sigmoid volvulus
Use flatus tube to decompress maximum 3 times
If it doesnt work sigmoidectomy
o Adhesions
If no peritonitis, and has a hx of operation, the pt can be observed
for 24 hours b/c may resolve as well as surgery may more
adhesions
Adhesiolysis
o Hernia
Commonly inguinal/groin (includes inguinal, femoral and
obturator hernias)
Tx: Hernia repair
o Intussusception
Tx: Explaratory Laparotomy
Somatic vs visceral pain
o Somatic pain
Localized
Knife like
Peritoneum supplied by T5 to L2 peripherally and C3 to C5
centrally.
When peripherally irritated, you get pain, tenderness and rigidity in
lower spinal nerves
When irritated centrally, pain is referred to the cutaneous
innervation.. C3 to C5 will cause shoulder pain.
o Visceral pain
Supplied by sympathetic branches of autonomic NS T6 to L2
Insensitive to touch via thermal/chemical/mechanical irritation
Sensitive to over-distension
Localised to developmental organ of viscus
Dull deep pain
#2: Intestinal Obstruction: Supine

Supine Abdxray showing SBO as evidenced by dilated central loops of bowel

with plicaecircularis (=circular mucosal folds) and central location
Supine Abd X-ray allows evaluation of the extent dilation and amount of amount
of distension and which part is dilated
Why take a supine Xray
o Doesnt show air fluid level
o Shows dilated bowel
o Rules out perforation
SMALL BOWEL ONLY AFFECTED WITH SMALL BOWEL OBSTRUCTION

Pic 313

#3: Intestinal Obstruction: Erect

 Pic 314
Erect Abdxray showing multiple ( >4) air fluid levels and dilated loops of small
bowel. Confirms SBO.
Erect Abd X-ray shows air fluid levels and pneumoperitoneum
Normal air fluid levels seen at ileocecal valve, 1st part of the duodenum and there
is a gastric bubble

Pic 392
Supine AbdXray showing dilated loop of large bowel.
Causes include- LBO secondary to colon cancer, stricture formation due to IBD-
Crohns disease, diverticulitis, post radiation, sigmoid volvulus, pseudo-
obstruction (Olgivies syndrome).
Mx of pseudo-obstruction - insertion of flatus tube or neostigmine(medical
decompression).
 NB: With large bowel obstruction BOTH THE SMALL BOWEL AND LARGE
BOWEL MAY BE AFFECTED!!!
o Large bowel with an incompetent ileocecal valve small bowel
distension, if it is competent there is no or very little or nor air fluids
levels. W/o distension perforation of cecum (Law of Laplace: pressure
buildup is directly proportional to the radius)

Pic 393-394
Erect Abd. Xray showing > 4 air fluid levels on the periphery which is in keeping
with LBO.
Central airfluid levels stepladder pattern of SBO
Peripheral air fluid levels LBO.

#4: Lateral Decubitus

This position is done when pt unable to stand up

Allows visualization of air fluid levels and pneumoperitoneum
Put patient on L side b/c this is the side with gastric bubble and therefore can
discern freee air under the diaphragm on right side

#5: Barium Swallow: Cancer of Oesophagus

 NB: Only SINGLE CONTRAST available w/ barium swallow
Double contrast barium enema air and barium (gives better resolution)
Identify if oesophagealCa applecore deformity, long irregular stricture w/ mass
effect, shouldering, and string sign fissuring and lack of proximal dilation. (In
achalasia, look for rat tail/bird beak deformity with proximal dilation.)
Filling defect suggests carcinoma
Malignant stricture oesophageal cancer
Most likely adenocarcinoma, which is usually seen in the lower 1/3 and usually
from Barretts oesophagus (metaplasia: Squamous Columnar)
Poor Px b/c compared to other GI malignancy it does not have a serosa and
therefore spread more rapidly and by the time pt becomes symptomatic it is
usually has metastasized
Dx w/ Bx
TNM Classification
o Primary Tumor (T)

TX: The primary tumor cannot be evaluated.

T0: There is no cancer in the esophagus.

Tis: This refers to carcinoma (cancer) in situ. Carcinoma in situ is

very early cancer, in which cancer cells are found only in one small
area and have not spread. Cancer cells are in only the top lining of
the esophagus without any spread into the lining.

T1: There is a tumor in the lamina propria and submucosa (the two
inside layers of the esophagus). Cancer cells have spread into the
lining of the esophagus.
 T2: The tumor is in the muscularispropria (the third layer of the
esophagus). Cancer cells have spread into but not through the
muscle wall of the esophagus.

T3: The tumor is in the adventitia (the outer layer of the

esophagus). Cancer cells have spread through the entire muscle
wall of the esophagus into surrounding tissue.

T4: The tumor has spread outside the esophagus into areas around
it. Cancer cells have spread to structures surrounding the
esophagus, including the aorta (large blood vessel coming from the
heart), windpipe, and diaphragm.

o Regional Lymph Nodes (N). The N in the TNM staging system stands
for lymph nodes, the tiny, bean-shaped organs that help fight infection. In
esophageal cancer, lymph nodes near the esophagus and in the chest are
called regional lymph nodes. Lymph nodes in other parts of the body are
called distant lymph nodes.

NX: The lymph nodes cannot be evaluated.

N0: The cancer was not found in any lymph nodes.

N1: The cancer has spread to one or two lymph nodes within the
chest, near the tumor.

N2: The cancer has spread to three to six lymph nodes within the
chest, near the tumor.

N3: The cancer has spread to seven or more lymph nodes within
the chest, near the tumor.

o Distant metastasis (M). The "M" in the TNM system indicates whether
the cancer has spread to other parts of the body.

MX: Metastasis cannot be evaluated.

M0: The disease has not metastasized.

M1: There is metastasis to another part of the body.

o Staging
Stage 0: Tis N0 M0
Stage I: T1 N0 M0
Stage IIA: T2 N0 M0
 T3 N0 M0
Stage IIB: T1 N1 M0
T2 N1 M0
Stage III: T3 N1 M0
T4 any N M0
Stage IVa: any T or N M1a
Stage IVb: any T, any N, M1b
o Tx depends on stage

Pic 415 -417

Ba swallow - Filling defect seen with shouldering, fissuring, dilated proximal
oesophagus. Likely to be Oesophageal cancer.
Classic apple core deformity seen

Pic 412 414 , 418

Ba swallow and follow-thru showing irregular lesions in oesophageal wall. Likely cause
ingestion of corrosive agent resulting in strictures.

#6: Intussception
#7: Intussception
Intusussception is commonest cause in infants
Claw sign (proximal section telescoping into distal section) seen on barium
enemaxray (check)
Causes of intussusception
o Idiopathic
o Lymphadenitis
o HenochScholenpurpura
o Merkels Diverticulum
o Polyps
Management
o Resuscitate
o Water soluble contrast
o Xray claw sign
o Barium enema - target sign
o Insufflate double contrast air and barium to try and reduce it
o If that doesnt work, surgical resection
o

#8: Barium Enema: Diverticula

 Pic
303,304,305
Double contrast Ba enema showing multiple diverticula in the large bowel.
Haustrations of colon seen. The presence of diverticulosis is shown by multiple
barium filled pockets especially in the sigmoid colon.
Risk factors
o Age: elderly
o Low fibre diet
o Increased stool transit time. (Laplaces law T= P x r ).
Diverticulosis (asymptomatic) vs Diverticulitis (clinical symptoms: painless
bleeding, perforated peritonitis, abscess)
Presents like an appendicitis now left sided!, PR bleed and constipation
Patient can also have
o Colocolonic fistula
o Colocutaneous fistula
o Colovesicle fistula
o Colovaginal fistula
Hincheys classification for fistula
1.Localised pericolic abscess
2. Mesenteric abscess
3. Perforation with purulent peritonitis
Perforation with feculent peritonitis
DDx of painless bleeding: Diverticulosis, Angiodysplasia, Malignancy
Investign: double barium enema
Has false diverticula because it contains mucosa and submosa, they occur at areas
of weakness due to increased intraluminal pressure due chonic constipation
increased segmental contractions of large bowel. NB: True diverticula involve
ALL layers of the bowel
 SxTx: Resect entire disease segment of bowel Hartmans procedure you dont
reanastomose right away because the bacteria will cause breakdown
Diverticulitis: can cause abscess, which can either obstruct or produce a mass or
perforate or fistulate

#9: Barium Enema: Apple Core Lesion CA

Double contrast barium enema (large bowel X-ray)

Allows mucosa wall to illuminate nicely and therefore allows mucosal
abnormalities to be better appreciated
Apple core lesion = malignant stricture
Types of strictures
o Benign
Smooth margins
o Malignant
Irregular
Shouldering
Filling defect b/c of ulceration
R vs L sided Lesions
o R: Ulcerative mass and liquefied stool
o L: Constricting mass and well formed stools
Dukes Staging (Original and Modified)
Pre-existing Conditions Colon Ca
o IBD
Pic 301
Single contrast BA enema with filling defect in rectum. Patient would present
with pr bleeding, constipation, obstruction, passage of mucus.
Ix: DRE, Proctosigmoidoscopy ,colonoscopy,Ba enema-only if colonoscope cant
pass lesion b/c misses up to 15% of rectal lesions. Must biopsy lesion to confirm
rectal cancer before performing surgery.
Sx: Ant. Resection for upper and middle 1/3 lesions; Abdomino-perineal resection
for lower 1/3 lesions with end-colostomy.

Pic 419
Ba enema - filling defect of large bowel,stricture secondary to cancer of colon.
Pic 420
Ba enema filling defect with distended distal colon. Cause may be colon cancer
A double contrast barium enema can show the typical apple core lesions of a
colonic carcinoma or multiple filling defects of colonic polyps.

#10: Barium Meal: Gastric Outlet Obstruction

Ba meal
May see filling defect,
May see very dilated stomach with no flow into duodenum. Know the causes of
gastric outlet obstruction PUD or CA and how to treat either. PUD-
truncalvagotomy and antrectomy. CA- curative or palliative resection.

#11: Barium Meal: Gastric Outlet Obstruction

Should not see anything in oesophagus unless there is distal obstruction
Pyloric Stenosis
o Pyloric stenosis is a narrowing of the pylorus, the opening from the
stomach into the small intestine.

o Pyloric stenosis also occurs in adults where the cause is usually a

narrowed pylorus due to scarring from chronic peptic ulceration. This is a
different condition from the infantile form.

o Congenital hypertrophic pyloric stenosis this condition occurs in infants

and is marked by a thickening of the pylorus which is the muscular band
of tissue in the stomach that controls the exit of food and gastric juices
from the stomach.

o Diagnosis

 Congenital

Projectile vomiting this vomiting occurs after feeds and is

first seen in infants several weeks after birth. To
experienced clinicians this alone is highly suggestive of this
condition

Presence of an olive on palpation often the

hypertrophic (overgrown) pylorus muscle can be palpated
(felt) on exam by an experienced surgeon. It literally feels
like an olive in the right upper quadrant beneath the right
costal margin (right rib cage) when direct, firm pressure is
placed.

o Pre-operative Workup and Preparation

Correction of electrolyte imbalance infants with pyloric stenosis

and vomiting typically have derangements of serum electolytes
such as low potassium and magnesium.

Correction of fluid balance this is done through an intravenous

line inserted peripherally and an infusion of 5% dextrose in normal
saline usually at the rate of 10ml/Kg. This is considered
maintenance fluid. Any preceding fluid deficit is then made up by
using 5% dextrose in alternating solutions of normal saline and
water for 12-24 hours or until adequate urine output has been
established.

Correction of acid/base balance this usually occur with

correction of the fluid deficit and potassium loss.

Placement of nasogastric tube after the diagnosis the infant oral

feeds for the infant are suspended. Although prolonged placement
of a nasogastric tube is to be avoided, sometimes 6-12 hours is
needed to prevent further vomiting.

o Sx: Ramstedt/Pyloromyotomy (Fredet-Ramstedt Operation)

Procedure

A small 3 cm incision is made in the skin with a No. 15

blade just below the right costal margin (the right rib cage)
 on the anterior abdominal wall, but above the inferior edge
of the liver.

Care must be taken to place the incision so that it extends

laterally from the outer edge of the rectus muscle.

Dissection is done through the subcutaneous tissues with

Bovie cautery.

The muscle layer is carefully divided using Bovie cautery

with the omentum or transverse colon presenting into the
wound.

Using very gentle traction on the omentum the transverse

colon if not already visualized through the wound can be
presented up into the wound.

Gentle traction on the transverse colon will then deliver the

greater curvature of the stomach up into the wound.

The anterior wall of the stomach is grasped with a moist

sponge and gentle traction on the stomach antrum is
applied this will deliver the pylorus into the wound.

The avascular (without blood supply) portion of the

anterior wall of the pylorus is identified.

The pylorus is held between the surgeons thumb and

forefinger and a 1-2 cm longitudinal incision (along the
plane of the pylorus) is made.

The incision is taken down through the serosal and muscle

layers until the mucosa is exposed.

Great care must be taken not to incise the mucosa. Extra

attention must be given to the duodenal end of the incision
as the muscle layer ends abruptly.

The incised (cut) muscle is gently spread apart with a

hemostat until the mucosa puffs up to the level of the cut
serosa.

The peritoneum and fascia of the transversalis muscle is

closed with a running absorbable suture.
 The remaining fascial layers are closed with either running
or interrupted slowly absorbable sutures.

The skin is closed with a subcuticular absorbable suture

such as Monocryl.

Collodian or adhesive Steri-strips are placed on the wound.

#12: Barium Meal: Hypertrophic Pyloric Stenosis

NB: Also on X-ray, fecoliths Especially as result of obstruction feces may become hard
and impacted

Pic 328
Ba meal revealing pyloric obstruction, enlarged dilated stomach, flocculations and
wall oedema.
Stomach largely dialted
Lots of filling defect (b/c of food particles)
 Distended dialted stomach, no contrast in duodenum, therefore suggests a gastric
outlet obstruction secondary to
o Benign
Seondary to PUD/DU
o Chronic
Secondary to Malignancy e.g. Gastric Cancer
Mgmt
o Correct electrolyte abnormalities, in this case
hypokalaemichyperchloremic metabolic acidosis with paradoxic acidosis
o NG Tube to decompress
o Endoscopy to see if malignancy present
o +/- CT done if unable to see on endoscopy b/c of site
Sx: Bilroth
o Malignancy: resect first

#13: T-tube Cholangiogram

Cholangiogram
A T-tube is use after exploration of the common bile duct and in addition to
decompression of the biliary tree immediately post-op, it facilitates a
cholangiogram about 7 to 10 days after surgery. Once there is no retained stones it
can be removed at this time as there is the formation of a fibrous tract along its
path. The T-tube tract can be cannulated under fluoroscopic guidance to facilitate
the removal of retained stones from the common bile duct.
Identify if operative, T-tube, percutaneous transhepatic or via a cholecystostomy
Know the anatomy of the biliary tree Rt and Left hepatic to from common
hepatic duct which is joined by cystic duct to form the common bile duct which
drains into the 2nd part of the duodenum

Pic 307
Plain Abdominal xray showing T-tube.
Pic 308
T- tubecholangiogram. T-tube in CBD.Indications for T-tube : 1) To decompress
biliary system following CBD exploration and allow drainage of the bile until
oedema at ampulla of Vater resolves. Removed after 7- 10 days by which time a
mature tract has formed to prevent leakage of the bile. 2) To perform T-tube
choloangiograminorder to assess the patency of the CBD. 3) To allow removal of
any remaining CBD stones.
Pic 312
Intraopcholangiogram with T-tube in CBD.
Pic 387-390
Cholecystostomycholangiogram
Pic 309
ERCP ( Endoscopic Retrograde pancreatico-Cholangiogram) .
o Procedure
Done under Sedation or GA
Pass Side view Duodenoscope into duodenum
Thread catheter under direct visualization into the ampulla
Inject contrast
Take serial x-ray pictures done under fluoroscopy
o Contrast delineates the distal biliary tree system.
o Negative filling defect seen in proximal half of CBD (see Film 2 down on
left ). ERCP has both diagnostic and therapeutic uses: allows investigation
of patient with obstructive jaundice and allows removal of CBD stones
detected respectively.
o Complications : Stricture formation
o Pancreatitis, Hpersensitivity to contrast.
Pic 397
Cholecystostomycholangiogram-self retaining catheter in Gallbladder, contrast
injected to delineate cystic duct, right and left hepatic ducts, common hepatic duct
and CBD.

Pic 391
Enteroclysis : NGT sited into duodenum and introduce contrast. Contrast pumped
in at great pressure with use of cellulose and air to create higher pressure. Used to
id small bowel lesions.

NB: A radio-opaque catheter on a plain abdominal film may be a feeding jejunostomy or

a peritoneal dialysis catheter. The tip of the peritoneal dialysis catheter usually sits in
the pelvis.

Classification of Polyps
Adenomatous (premalignant)
 Non-adenomatous (hyperplastic, inflammatory, normal) polyps

?Fill in?
Renal X-rays
1. Bilateral Renal/Ureteric Calculi
2. Bladder Calculus
3. Hydronephrosis
4. Urethrocystogram
Urethral Stone
5. Double J Stent
6. Left Multiple Renal Calculi
7. Hydronephrosis

#1: Bilateral Renal/Ureteric Calculi

X-ray description: Bilateral multiple renal stones

Shape makes it self retaining to help keep it in place
Causes
o Hypercalcaemia b/c of
Hyperparathyroidism (*KNOW primary, secondary and tertiary)
Malignancies
Assessment of renal function

X-ray description: Multiple renal calculi

Presentation: Asymptomatic (rarely)
Investigations
o Renal function test: urea, creatinine
Want to know aetiology

#2: Bladder Calculus

 X-ray description: Well circumscribed circumferential opacification; onion peel
appearance (infection adds on the layers)
Causes:
o Neurogenic bladder (seen in paraplegic)
o Bladder diverticuli
DDx: Foreign body in rectum/vagina e.g. Drug Mule (used in drug trafficking)
if suspected as pt to squat and cough

#3: Hydronephrosis

X-ray description: 3 serial IVPs showing a stricture at level of L5,

hydronephrosis; mention time on X-ray
 NB: KUB is done before IVP and is called a pilot. Bowel prep is done to ensure
no air is in the bowel to obstruct the vision therefore why KUB done first ahd then
do IVP
Zero film: time of injection of contrast = nephrogram b/c contrast enters the
nephrons. Tells if there is good blood flow
Causes of narrowing:
o Intraluminal (within the lumen of the ureter)

o Extraluminal (outside the ureter)
o Mural (within the wall)
The most common points for obstruction to occur are the ureteropelvic junction
(UPJ), the crossing of the ureter over the area of the pelvic brim (the iliac
vessels), and the ureterovesical junction (UVJ).
Causes:
o Strictures
Most likely due to
Male: prostatic cancer
Females: cervical cancer
o Stones
Tx: Double J Stent to relieve obstruction (self retaining b/c of shape)
NB: CT urogram gives a better form of investigating b/c it gives a complete
analysis of the kidney
#4: Urethrocystogram

X-ray description: This is an X-ray of a retrograde urethrocystogram the bladderis

well circumscribed and there is extravasation of the contrast
Catheter is placed into the tip of the penis and the bulb is inflated in the penile
urethra (b/c rupture normally occurs in membranous urethra)
Indications
o Bladder neoplasms
o Strictures
Instrumentation
Gonoccocal infection
Anatomy of the ureter
Pic 398
Retrograde or Ascending urethrogram detects urethral strictures secondary to trauma,
post-GC infection etc.

Pic 399 - 400

MCUG showing extravasation of contrast from penile urethra.May be due to urethral
trauma secondary to pelvic fracture.(Extravasation of urine into abdomen Watering can
penis).
Pic 401-402
MCUG showing multiple strictures in the penile urethra.

Pic 403
Retrograde pyelogram showing extravasation of contrast from urethra into the pelvis.May
be due to pelvic fracture with urethral trauma.
Pic 405
Retrograde urethrogram showing urethral stricture in penile urethra with Foley catheter
in-situ.

#4: Urethral Stone

#5: Double J Stent

X-ray description: this is a KUB showing a Double J Stent

Used to treat obstruction
Keeps ureter patent e.g. stone, strictures, repair of ureter, prophylactly for end
stage
Shape makes it self retaining to help keep it in place

#6: Left Multiple Renal Calculi

 X-ray Description: this is a KUB showing the entire pelvis; radiopaque region
demonstrating renal calyces, stone in L kidney shaped as pelvic calyx system
Presentation: painless haematuria
Dx: Renal calculi
DDx: Gall Bladder Calculi NB: Lateral X-ray to distinguish b/w kidney stone (on
level of the spine) and gall stone (anterior to spine) only 10% are radiopaque
and if they are, they are not cholesterol stones

#7: Hydronephrosis

X-ray description: papillae of calyx is dilated, dilates and tortuous ureter,

hydroureter in proximal 2/3
IVP gives anatomy and function
DDx
o Vesicourethral reflux
o Posterior urethral valves (bilateral; infants)
Can not comment on a stricture in a static film
Pic 421
20 minute IVP film showing Double ureters with dilated left pelvi-calyceal
system/left hydronephrosis.
Two ureters on right side. Dilatation of pelivicalyceal system of left kidney as
evidenced by loss of cupping of the calyces and also absence of the left ureter.

Pic 422
IVU showing obstruction in the left ureter.
Orthopaedics X-rays
1. Lower End Tibia Bony Lesion
2. Lower End Radius Bony Lesion
3. Colles Fracture
4. Shoulder Dislocation
5. SupacondylarHumerus Fracture
6. Femur Fracture
7. Osteoarthrtis of Hip
8. Hemiarthroplasty
9. Fracture of Neck of Femur
10. Knee Dislocation
11. Tibia Fibula Fracture
12. Compound Fracture of the Humerus (GSW)
13. CT Scan EDH
CT Scan SDH
Limbs
Define if proximal. mid shaft or distal #
If it is transverse, oblique, spiral or greenstick
Know how to manage them!!
Manual reduction vs. ORIF

#1: Lower End Tibia Bony Lesion

Non-osssifying Fibroma (also called fibroxanthoma)

o Well marginated oval shaped areas of radiolucency in or adjacent to
cortex, with a distinct multilocular appearance.
o Usually asymptomatic and is an incidental finding on X-ray; occasionally
multiple lesions
o It is the most common benign bone tumor in children and adolescents.

However, it is controversial whether it represents a true neoplasm

or rather a developmental disorder of growing bone

o These foci consist of collagen rich connective tissue, fibroblasts,

histiocytes and osteoclasts. They originate from the growth plate, and are
 located in adjacent parts of the metaphysis and diaphysis of long bones,
most often of the legs.

o No treatment is needed in asymptomatic patients and spontaneous

remission with replacement by bone tissue is to be expected.

o Multiple nonossifying fibromas occur in Jaffe-Campanacci syndrome in

combination with cafe-au-lait spots, mental retardation, hypogonadism,
ocular and cardiovascular abnormalities.

o DDx
Brodies abscess
Osteoarthritis (Chronic)
#2: Lower End Radius Bony Lesion

Description: AP of forearm, distal femur and hand showing a radiolucent

obstructing lesion in the distal aspect of the radius, the lesion is expansile with
significant cortical erosion and some soft tissue shadowing, and is fairly
geographic. Cortex appears thin, expanded; well demarcated sclerotic margin
Giant Cell tumor
o Benign aggressive lesion
o Sites
Distal femur
Distal radius
Proximal humerus
Proximal tibia
o 1/3 locally invade, 1/3 stay truly benign, 1/3 metastasize
o Presentation
80% occur >20 y.o., average 35 y.o,

Patients usually present with pain and limited range of motion

caused by tumor's proximity to the joint space.

There may be swelling as well, if the tumor has been growing for a
long time.
 Some patients may be asymptomatic until they develop a
pathologic fracture at the site of the tumor.

The symptoms may including muscular aches and pains in arms,

legs and abdominal pain.

Patients may also experience nerve pain which feels like an electric
shock.

o Tx
Blood
CBC (WBC Infection)
Liver enzymes
PSA (Old male)
Clacium phosphate
Urine
Bence Jones proteins (MM)
Imaging
CT Chest and Abdomen
MRI
Bone scan and skeletal survey
Bone Bx
Do investigations before this because it can change bony
architectecture
The key histomorphologic feature is, as the name of the
entity suggests, (multinucleated) giant cells with up to a
hundred nuclei that have prominent nucleoli. Surrounding
mononuclear and small multinucleated cells have nuclei
similar to those in the giant cells; this distinguishes the
lesion from other osteogenic lesions which commonly have
(benign) osteoclast-type giant cells.
Based on whether well-defined and growth rate
Slow growing w/ benign histology
o Curettage
o Stripping
Aggressive
o Excision
o Bone graft
o Prosthetic placement
o Px: 30% recur w/I 2 yrs of Sx
o DDx:
Telaniectactic Osteosarcoma
Malignant bone tumor that can mimic GCT
 Llinical presentation closely resembles that of conventional
osteosarcoma. However, local pain, soft-tissue masses, and
fractures are the most common presenting symptoms and
signs.
Occurs in a male-to-female ratio of 2:1. Although disease
can be found in patients aged 3-71 years, it rarely occurs in
persons older than 25 years. Most patients present when
they are aged 10-20 years
Sites

o Distal femur - 48%

o Proximal humerus - 12%

o Proximal tibia - 10%

o Proximal femur - 8%

o Fibula - 5%

o Midfemur - 2%

o Midhumerus - 2%

Infection e.g. Brodies Abscess

#3: Colles Fracture

Colles fracture, gives dinner fork deformity, distal fragment shifted dorsally
and angulated radial. Reduction traction and pronation
Reduction
o Under anaesthesia
Hematoma block
Go under the fracute site
Blood should NOT be frank blood,
Behrs block
 Axillary block
o Traction
o Flexion (moderate)
o Ulnar deviation
o Check position w/ X-ray
Tx
o Stable
Colles plasterback slabdoes not extend beyond
themetacarpophalangial joint. Leaves all fingers including thumb
exposed.
o Unstable
K-wire
o Extremely Unstable
External fixation

#4: Shoulder Dislocation

#5: SupacondylarHumerus Fracture

Commonly seen in children

Presents with pain and a swollen elbow
Commonly due to falls on an outstretched hand
Gartland Classification
o Type I:
Nondisplaced
Tx closed reduction and external immobolisation
o Type II:
Displaced with intact posterior cortex
Tx is surgery w/ closed reduction and percutaneous pining w/ K-
wire and fluoroscopic guidance
Pic 406
Spiral fracture of humerus. Likely injuries include damage to radial nerve which
runs in the spiral groove, axillary nerve damage and injury of the brachial artery.
Need AP and lateral views to determine is fracture is displaced.ORIF with plates
and screws needed.

#6: Femur Fracture

Description
o Fracture of the distal 1/3 of femur
o Mgmt
1st step: reduction under conscious sedation
*Do thorough neurovascular exam*
Nerves
o Deep peroneal nerve
Sensory: 1st dorsal web space of foot
Motor: Dorsiflexion of foot
o Superficial peroneal nerve
Sensory: lateral leg
Motor: Eversion of foot
o Anterior tibial nerve
 Sensory: Sole of foot
Motor: plantar flexion of foot
Vascular
o Capillary refill
o Posterior tibial and dorsalispedis pulses
o Colour of limb
Ankle Brachial Index (objective)
o Normal = 1
o <0.8/0.9: significant; do arterial screen e.g. CT
angiogram
Preop photo
Debride wound
Traction or external fixation
Plate or intermedullary nail
Compartment release (fasciotomy)
Anterior, lateral, deep, superficial compartment in leg
Pain disproportionate to injury. Illicited by stretching of
toes
Pulseleness and pallor are LATE SIGNS (do not mention
these first)
Occludes at 30mmHg
o
Proximal Femur- fractures of the Head are rare, and are associated with hip
dislocation
o Subcapital&transcervical are intracapsularjeopardise blood supply to
head leading to avascular necrosis.(Seen in SS disease also).
o Trochanteric and subtrochanteric fractures are extracapsularnot at risk
of avascular necrosis
Other femoral fractures affect femoral shaft and these are seen in young adults
where high energy is transferred eg. Motor vehicle accidents, supracondylar and
knee joint (intra-articular). Remember that significant blood volumes (up to 2 L)
can be lost in the thigh of a femoral shaft fracture.
Complications of femoral fractures include, avascular necrosis of the head of
femur and nonunion which especially affects intracapsular fractures

#7: Osteoarthrtis of Hip

Features of Osteoarthritis
o Decreased joint space/join space narrowing
o Subchondral cysts
o Sclerosis
o Osteophytes
 Dx
o Usually in an older individual
o Gradual onset of gorin/medial
thigh pain, increasing w/
activity
o Limb shortening
o Decreased internal
rotation/abduction of hip
o Fixed flexion deformity
o Positive Tredelenberg sign
Tredelenberg Test
Pt stands on affected leg, normally gluteus medius muscle
on ipsilateral side contracts to keep pelvis level
Positive test = contralateral side drops prpt compensates by
leaning way over supported leg
o X-ray
Tx
o Non-operative
Weight loss
Walking aids
Physiotherapy
Analgesia (acetaminophen)
NSAIDs (anti-inflammatory)
o Surgery
(If medical tx fails; do total joint replacement)
Realign: Osteotomy
Replace: Arthroplasty
Ablate: Arthrodesis, Excision
o Rheumatoid v.s. Osteoarthritis
RA
Global inflammatory arthritis therefore typically involves
whole joint, lateral compartment 1st than all of it
Symmetrical pattern, therefore e.g. loss of joint space on
both sides
OA
One compartment 1st
Hip: weight bearing part affected 1st
Degenerative
Can be asymmetrical
#8: Hemiarthroplasty
#9: Fracture of Neck of Femur

Description
o AP of R hip showing proximal neck of femur
o Intracapsular fracture
o Gardens type 4
Risk
o Nonunion
o Malunion
o Avascular necrosis
o DVT and PE
Tx
o Use biological age rather than chronological age
o Depeneds of physiological age, level of activity and grade of fracture
Gardens 1 and 2: Internal Fixation to prevent displacement
Gardens 3 and 4
<55:
o reduction with internal fixation w/I 12 hours of
fracture;percutaneous screw
55-70:
o Total hip replacement (femoral stem and
acetabulum)
> 70
 o Hemiarthroplasty
Unipolar hemiarthroplasty (Austin Moore
Prosthesis)
Complications:
o Metal toxicity
o Pneumonia
o Dislocation
o Fracture w/ placement
o Fat embolism
Bipolar hemiarthoplasty
Active elderly patient because of
extra-articular surface

Pic 407-408
Osteogenesisimperfecta with old fractures of tibia and fibula showing malalignment and
malunion with shortening of the tibia.

#10: Knee Dislocation

Description: Later X-ray of the knee joint, femur, tibia and fibula showing
anterior dislocation of the knee joint
*Neurovascular Exam*
o Nerves
Deep peroneal nerve
 Sensory: 1st dorsal web space of foot
Motor: Dorsiflexion of foot
Superficial peroneal nerve
Sensory: lateral leg
Motor: Eversion of foot
Anterior tibial nerve
Sensory: Sole of foot
Motor: plantar flexion of foot
o Vascular
o Capillary refill
o Posterior tibial and dorsalispedis pulses
o Colour of limb
o Ankle Brachial Index (objective)
o Normal = 1
o <0.8/0.9: significant; do arterial screen e.g. CT angiogram
o
MRI Angiogram preferred b/c no gross bony injury

#11: Tibia Fibula Fracture

#12: Compound Fracture of the Humerus (GSW)

Fractures of humerus include-Surgical neck, anatomical neck, greater

tuberosity, shaft, supracondylar and transcodylar fractures.
 Supracondylar fractures are serious in children, there is backward shift of
distal fragment with possible interruption of blood supply to the forearm radial
pulse and colour of the hand must be checked frequently. In a patient with a supra
condylar fracture and absent distal pulses the first measure is to reduce the
fracture as in 50% of cases there is just kinking of the vessel by the angular
deformity.

#13: CT Scan EDH and CT Scan SDH

Computed tomography scan of the brain showing an acute epidural haematoma
or an acute subdural haematoma is often present.
In addition to the radiological differences (epidural limited to the origins of the
dura on bone and comes from arterial bleeding, usually middle meningeal artery)
the clinical differences including the lucid interval should be discussed.
Look for evidence of midline shift on the CT scan and other features of raised
intracranial pressure including effacement of the 3rd ventricle.
Emergency measure to reduce intracranial and minimize secondary brain injury
including oxygen therapy, ensure adequate blood pressure and preventing
hypercarbia and possible mannitol.
The siting of an intracranial pressure monitor may also be useful
CT Scan EDH

CT Description: Biconcave shaped (lenticular-shaped hematoma) hyperdense

lesion; midline shift; limited by suture lines. Classic presentation: lucid interval
Collection of blood between the skull and dura
Usually occurs in assoc w/ a skull fracture as bone fragments lacerate meningeal
arteries
Middle meningeal artery
Most common sign: >50% have ipsilateral blown pupil
Classic Hx: LOC followed by lucid interval followed by neurolgic deterioration
Surgical Treatment: Surgical evacuation
o Indications: Any symptomatic epidural hematoma; any epidural hematoma
>1cm
CT Scan SDH
 CT Description: Curved, crescent shaped hematoma
Blood collection under the dura
Caused by tearing of bridging veins that pass through the space b/w the cortical
surface and the dural venous sinuses or injury to the brain surface w/ resultant
bleeding from cortical vessels
3 types of subdurals
o Acute
Symptoms w/I 48 hours of injury
o Subacute
Symptoms w/i 3-14 days
o Chronic
Symptoms after 2 weeks or longer
Tx: mass effect (pressure) must be reduced. Craniotomy w/ clot evacuation is
usually required

Pelvic X-Ray
Know the complications damage to pelvic venous plexus and viscera, thus put
on external fixator to decrease the volume of the pelvis and thus decrease
bleeding.
Pelvic X-rays showing various combinations of fractures to the pelvic bones is
usually present to form a basis for discussion of the risk of blood loss from
ruptured venous plexuses and hence resuscitation. In addition the possibility of
hallow viscus injury including the urethra which is usually suspected from blood
at the tip of the urethral meatus or a scrotal haematoma or a high riding prostate
on DRE.
Pic 404
Pelvic Xray showing open book pelvic fracture (pelvic diastasis)
5 views: AP, Inlet, outlet and 2 obliques

Types of Non-Union: 1) Hypertrophic-excess callus around fracture site. 2) Atrophic- no

callus formation.

Pic 409
Chronic osteomyelitis of the ulna.Mottled appearance of the bone with periosteal
reaction.

Fracture of carpal bones:

The most common is scaphoid fracture-60-70%.Often missed and diagnosed as
a sprained wrist.
Injury occurs following a fall on outstretched hand usually in a young adult.
Presents with pain in the wrist with tenderness over the anatomical snuffbox but
there is usually little wrist swelling.
Xrays must not only include anteroposterior and lateral views but also must
include two oblique views of the wrist .A repeat radiograph may be necessary
2 weeks after ifnofracture is seen at the time of injury, because sometimes the
fracture is not obvious on the initial films until after bony resorption. T
he plaster used to treat scaphoid fracture must extend beyond the proximal
metacarpophalangial joint of the thumb leaving other mp joints free.
Complication -- scaphoid non union which is treated by internal fixation

Monteggia and Galeazzi Fracture-dislocations of the Forearm

Introduction
o The Monteggia and Galeazzi are unstable fracture-dislocations of the
forearm.
o The Monteggia fracture-dislocation features a dislocation of the radius at
the elbow
 o The Galeazzi fracture-dislocation involves a dislocation of the ulna at the
wrist.
Monteggia Fracture

There is a fracture of the midshaft of the left ulna with 20 degrees of angular
displacement. The proximal radius does not align with the capitellum

The proximal radial line should always pass through the centre of the capitellum

This is referred to as a Monteggia fracture (In a true lateral the bones should overlap, not
be side by side)

Galeazzi Fracture
There is a The displacement The radiographer noted the
displaced of the radial scaphoid fracture (white
oblique fracture fracture and the arrow) and another bony
of the mid/distal dislocation of the fragment between the distal
1/3 of the radius. ulna at the distal radius and ulna (black
There is also an radio-ulnar joint arrow). The avulsed
abnormal (DRUJ) are better fragment is sourced from
positive ulnar demonstrated in the ulnar styloid. It was
variance of the this view. The considered that a dedicated
wrist. appearance is wrist view was warranted
typical of a
Galeazzi fracture-
dislocation.
Tx

o Reduce, restrain, rehabilitate

Child: reduce and cast

Around joints: fix surgically b/c stiffness

Femur: fix surgically b/c hard to ?immobolize?

o Neurovascular exam

Median nerve

Ulna nerve

o Compartment syndrome can occur

Vollar compartments: deep and superficial

Extensor

Flexor
SUFE (X-ray will only have a slight change therefore look CAREFULLY!!!)

Features
o Kleins line
o Widening of physis
o Blanch sign (whiteness)
Presentation

o Limp, knee/thigh pain (obturator nerve referred from hip), hip irritable
(obligate extension on rotation of hip)

Classification

o Acute v.s. Chronic

o Stable v.s. Unstable

ALL admitted and have bed rest until able to place pin (single cannulated screw)
and stabilize with gentle reduction (NEVER FORCED!!)

Osteosarcoma

X-ray features
o Nongeographic: border b/w

o Sunburst pattern/periosteal rxn

 o Cortical breakthrough

Investigations

o Bloods e.g CBC, Smack 25

o Imaging e.g. X-ray, MRi of entire femur for skip lesions

o Bone Bx

Consult with ortho

DDx

o Osetosarcoma

o Ewings

NB: Physis is a biological barrier, if a lesion crosses it, it is malignant

 Anaesthesia X-Rays

1-2. Foreign Body in Stomach

1. Pneumothorax
2. Lines

# 1 & 2: Foreign Body in Stomach

#3: Pneumothorax

Look at CXR for pneumothorax, lung edge away from bony chest wall.
May be a spontaneous pneumothorax. Usually in spontaneous pneumothorax
there is evidence on the CXR of underlying lung disease such as bullae or
hyperinflated lung fields.
Air fluid level on chest X ray usually means haemo-pneumothorax which
usually occurs after trauma. This should be distinguishable from a pleural
effusion which usually has a meniscus at the upper border of the fluid.
A tension pneumothorax, though not a common radiological finding is often
present in the exams and the discussion of its emergency management is a must
by the candidate. This includes the passage of a wide-bore cannula in the 2nd
intercostal space, mid clavicular line of the affected side with an expected gush of
air.

#4: Lines
 Radio opaque line on CXR may indicate a CVP Line.
Similarly a pacemaker may be visible on the CXR.

Breast X-rays

1. Mammogram
2. Needle Localisation

#1 = Mammogram

Figure 1. Digital mammogram (1a), right and left cranial-caudal views, shows an
area of asymmetry in the lateral right breast. The right and left medial-lateral
oblique views (1b), show an area of asymmetry in the upper right breast.
X-ray description: Hyperdense mass, large, speculated, irregular
Types
o Diagnostic: 3 views
o Screening: 2 views CC and MCO
#2 = Needle Localisation

If small and impalpable

Done in radiology
Biopsy sample of mass
Send back to radiology once excised to ensure all is removed
 Take to pathology