07 radiology in surgery tutorial hajhamad m msu

Radiology in surgerydiagnosis and therapy

Dr. Mohammed HajhamadMB.ChB. (Egypt) M.S (Malaysia)

Department of SurgeryInternational Medical School

Management and Science University

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May 1, 2023

Objectives

1. Become familiar with the basic techniques and principles of

radiological investigation

2. Understand the principles of selection of the most

appropriate radiological technique for a given clinical

problem.

3. Identify the key roles of radiology in the diagnosis and

management of surgical disorders.

4. Understand the principles and indications for radiotherapy in

surgical diseases.

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Remember …

No radiological technique replaces clinical skills.

Do not base clinical decision making on imaging findings alone.

“ Treat the patient and not the X-ray”

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How are radiological techniques used in surgery?

To aid in the diagnosis of a surgical disorderAs an interventional technique to treat a surgical disorder or one of its complicationsTo guide a surgical procedure.

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Today’s topics

X-raysUltrasoundComputed tomography (CT)Magnetic resonance imaging (MRI)Nuclear medicine.Interventional radiologyRadiotherapy

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History

WILHELM CONRAD RONTGENFather of radiologyInvented X-ray in 1895

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http://www.roentgen-museum.de/museum/index.html

History

SIR GODFREY HOUNSFIELDFather of CTInvented CT in 1975

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Radiographs, the basics

The five radiographic densities are in order of increasing brightness:

I. Air2. Fat3. Fluid4. Bone5. Metal.

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Too darkOver exposure

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Too brightUnder exposure

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Sharpness Experiment

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CT scan and MRILamp and the desk are spinning rapidly around your finger.

(experiment)

This situation is analogous to a

In CT scan (Computed Tomography), the x-ray tube (lamp) and the

detector (wall) spin rapidly around the patient.

Information is transferred to a computer and multiple images are

reconstructed.

CT images give the impression of looking at cross-sectional slices of

the patient.

MRI (Magnetic Resonance Imaging) generates cross-sectional images

using a large magnetic field.

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CT and MRI

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Ultrasonography, the basics

Piez0-electric effectPiezo (in Greek) means: squeeze.

Piezoelectric Effect is the ability of certain materials to generate an electric charge in response to applied mechanical stress.

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An ultrasound wave is generated when an electric field is applied to an array of piezoelectric crystals located on the transducer surface. Electrical stimulation causes mechanical distortion of the crystals resulting in vibration and production of sound waves.

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Ultrasound: sound waves at higher frequencies than can be detected by human being (>20,000 Hz)In medicine, we use very high frequency between 2-20 MHz.

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Acoustic impedance (Z) is a physical property of tissue. It describes how much resistance an ultrasound beam encounters as it passes through a tissue. Acoustic impedance depends on: the density of the tissue (d, in kg/m3) the speed of the sound wave (c, in m/s)

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How difficult its for a sound wave to penetrate material?

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Nuclear imaging

Radio-isotops (radiopharmaceuticals) are given intravenously or orally. Then, external detectors (gamma cameras) capture and form images from the radiation emitted by the radiopharmaceuticals. There are several techniques of diagnostic nuclear medicine.

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Examples Whole body bone scan – used to identify metastatic cancer involving the bone.Thyroid uptake scan – used to visualize the thyroid gland when disease of the thyroid is suspected.Renal scan – used to indicate the perfusion, function and structure of the kidneys. It is also used to indicate the presence of obstruction or renovascular hypertension.Parathyroid scan – done primarily to detect tumors in the parathyroid gland.Liver/spleen scan – allows for visualization of the liver and spleen. It is indicated for patients with cancer to rule out metastatic tumor in the liver.

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Examples technetium-99m rubidium-82 thallium-201 fluoro-deoxy glucose (FDG)

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Examples

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Theraputic radiologyRadiotherapy A clinical modality dealing with the

use of ionizing radiation in the treatment of patients

Cancer treatment

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How Radiotherapy Works ? DNA

Translocations Deletions

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Types of Radiotherapy

•External Beam Radiotherapy: radiation source is outside the patient

•Brachytherapy: radiation source is inside the patient: Intra-cavitary (cervix cancer) Intra-lumenal (esophagus, bronchus) Interstitial (Head Neck, Breast)

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External Beam Radiotherapy

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Interstitial

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Interventional radiology

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What is interventional radiology?

Interventional radiology is a subspecialty which provides minimally invasive diagnosis and/or treatment using imaging (ultrasound, CT, or fluoroscopy) to target the intervention and show the results of the intervention.

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1. Percutaneous biopsy

US, CT or fluoroscopyRandom sampling or sampling of a massLung, mediastinum, pleura, chest wall, nodesLiver, adrenal gland, pancreas kidneys, lymph nodes

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Liver biopsy

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Lung biopsy

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2. Percutaneous abscess drainage

US, CT or fluoroscopyAspiration or drainage tube placementUsually for infectionPleura, lungHepatic (intra/sub), pericolic gutters, perisplenic, peri/intrapancreatic, pouch of Douglas, psoas, abdominal wall

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3. Arteriography

Injection of contrast media directly into arteries and vis via fluoroscopyUsually immediately precedes and intervention is angioplasty, stenting, embolization, thrombolysisAorta, pelvis, lower and upper extremities, kidneys, gut, lungs

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Aortic angiography

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Pelvic embolization post trauma

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13. Foreign body retrieval

Most frequently guidewires or cathetersUsually in the right heart or pulmonary arteryRetrieval under fluoroscopic guidance using snares needed given infection, arrhythmia risk

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Cholangiogram (L), internal external drainage from the L (R)

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Jom ... practice

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RADIOLOGY DIAGRAM

X-ray image

Pathologyimage

Zenker's Diverticulum

Esophageal Cancer

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Benign Esophageal Stricture

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Achalasia

NORMALESOPHAGUS

DIAPHRAGM

HIATAL HERNIA

DIAPHRAGM

*Note distended distal esophagus with herniation of gastric fundus into chest through esophageal hiatus.

This allows for reflux of gastric contents into esophagus.

Diffuse Esophageal Spasm

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Gastric Ulcer

Barium collects in ulcer crater

Endoscopic view of ulcer

Malignant Ulcer Benign Ulcer

Gastric Carcinoma

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Duodenal Ulcer

Supine … Looking for:Gas in the

rectum/sigmoidGas in ascending or

descending colonDistended loops

Erect .. looking for:free air “under

diaphrams”air-fluid levels

Normal Gas Pattern

○ Stomach Always (except

supine)○ Small Bowel

Two or three loops of non-distended bowel

Normal diameter = 2.5 cm = 1 US quarter

○ Large BowelIn rectum or sigmoid –

almost always

stomach

colon

· Large Bowel¨ Peripheral¨ Haustral markings don't extendfrom wall to wall· Small Bowel¨ Central¨ Valvulae extend across lumen¨ Maximum diameter of 2"

HEPATIC FLEXURE

SPLENIC FLEXURE

TRANSVERSE COLON

CECUM

ASCENDING

COLON

DESENDIN

G COLO

NTERMINAL ILEUM

Normal Colon

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An erect CXR (not AXR) is the best projection to diagnose a pneumoperitoneum (gas in the peritoneal cavity).

Other Signs of Free Air Rigler's sign

air is present on the inside (lumenal side) and the outside (peritoneal side)

ERECT

Ng tube

Small Bowel Obstruction


DilatedBowel

Non DilatedBowel

OBSTRUCTION*

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Hernia

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ColonObstruction

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Colon Cancer

Sigmoid Volvulus

“coffee bean sign”

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“beak sign”

Barium fills to point of obstruction and

twist of sigmoid colon

Colon Volvulus

Intussusception Meniscus sign

Chrohn’s Disease

normal

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Chrohn’s Disease

String Signcobblestone mucosa

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Ulcerative Colitis

Lead Pipe Colon ahaustral appearance

Diverticulosis

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Diverticulitis

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Appendicolith

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Ileostomy

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Gall Stones

Porcelain Gallbladder

Nephrocalcinosis

•Hyperparathyroidism •Medullary sponge kidney

ERCP - Normal

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Bile Duct Stricture

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MRCP

Small Bowel ObstructionPROXIMAL DILATED

BOWEL

DISTALNORMALBOWEL

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Peritoneal Free air

Retroperitoneal Air

Pneumoretroperitoneum

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Polyp of Transverse Colon

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Gastric Tumor

Tumor of Rectum

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Tumor of Rectum

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Pneumatosis Intestinalis

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Pneumatosis Intestinalis

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Pneumobilia

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GS ilues

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Amebic Liver abscess

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Gas-producing Organisms

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Pyogenic Abscess

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Liver Metastases

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Hepatocellular Carcinoma

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Hernia

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Inguinal Hernia

Appendicitis

NORMAL

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DrainageAbscess

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AAA

Pancreatitis

Carotid Body Tumor

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T1

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Gallbladder Stones + Wall Thickening

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focal CBD dilatation in the distal part

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Anechoic Liver Lesions

CBD is dilated measuring 1 cm with tiny stone

multiple gallstones with mild thickening

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Malignant Breast Lesion

Pathological Axillary Lymph Node

07 radiology in surgery tutorial hajhamad m msu

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