Thoracic and Abdominal Radiology - MemberClicks - Thoracic Abdomin...2019 PM Conference - Diagnostic...

2019 PM Conference - Diagnostic Imaging

10/19/2019

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Thoracic and Abdominal Radiology

Krikor G. Arman, II, MD

General Surgery, Trauma Surgery, Surgical Critical Care

Beaumont Grosse Pointe

Questions/Comments/Feedback: [email protected]

Disclosures

• None

• Images borrowed from Dr. Google

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Outline and Goals

• Systematic approach to CXR interpretation and Thoracic pathology

• Systematic approach to AXR interpretation and Abdominal pathology

• Brief intro to CT interpretation

• Main Goal: Correlate clinically…

My two cents…

• Don’t order a study unless you know what you’re looking for, and if it will change your management

• Always look at images first before you read the radiologist interpretation

• Go over images with radiologist, surgeon, anyone who is willing to take the time

• Be a practitioner…

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CXR: Systematic Approach

• Always start by confirming correct patient, study

• Look for prior studies to use for comparison


• Assess image quality with “RIPE”

• R: rotation

• I: inspiration

• P: positioning

• E: exposure

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• R: rotation

• Clavicular heads equidistant from spinous processes

• Spinous processes centered on vertebrae


• I: Inspiration

• Would like to see at least 8 ribs, lung apices, costophrenic angles, and lateral rib margins

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• P: projection/positioning

• AP vs PA

• Supine, upright


• E: exposure

• Look to see if the film is over- or under-exposed (ie: too bright or too dark)

• Should see the diaphragm behind the spine and the vertebrae behind the heart

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• Interpretation: The ABCDE method

• A: airway

• B: breathing

• C: cardiac

• D: diaphragm

• E: everything else


• A: Airway

• Trachea should be midline (more or less)

• It can be pushed or pulled by different pathology

• Look at mainstem bronchi

• Right is shorter, wider and more vertical than left

• Look for carina to measure endotracheal tube (should be 2-6 cm above carina)

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• B: breathing

• Look for lung markings in all fields

• Atelectasis

• Pulmonary edema

• ARDS

• Pneumonia

• Mucus plug/white out

• Pleural effusion, hemothorax

• Nodules/Tumors

“White out”

• Mucus plug

• Giant pleural effusion

• Large hemothorax

• Large mediastinal tumor

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• C: cardiac

• Heart should be less than 50% of the total width of the chest on a PA image (will look bigger on AP)

• Heart borders:

• Right is the right atrium, left is the left ventricle


• D: diaphragm

• Right hemidiaphragm is higher than the left (usually)

• Look for sharp vs blunted costophrenic angles

• Look for gastric bubble on the left

• Look for free air

• Chilaiditi syndrome: colon superimposed over the liver, looks like free air

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Diaphragm rupture

• Most commonly on the left…


• Everything else:

• Lines: Central line, pacemaker leads, PICC line, mediport

• Tubes: ETT, NGT, nasoenteric tube

• Mediastinum: widening, aortic knob, aortopulmonary window, artificial valves

• Hilar structures

• Bones: look for fractured clavicles/ribs, flail chest

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NGT

Flail Chest

• Two fractures in three consecutive ribs

• Flail segment has paradoxical movement

• Pulmonary contusion

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A

B B

CD D

E

E

Summary

Outline




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AXR: Systematic Approach

• Always start by confirming correct patient, study

• Look for prior studies to use for comparison

• Don’t order a study unless you know what you’re looking for, and if it will change your management


• Assess image quality

• P: positioning (supine, upright, lateral decubitus)

• E: exposure (make sure entire abdomen is included)

• Type of image

• 1 view (supine; “KUB”)

• 2 view (supine, upright)

• Acute abdominal series (CXR plus 2 view)

• 3 view (supine, upright, lateral decubitus)

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• Decide which study to order based on what you’re looking for

• 1 view (supine): good for tubes, contrast progression, but not for free air or air-fluid levels

• 2 view: air-fluid levels, free air

• 3 view: gives an additional view for free air


• Interpretation: The BBC method

• B: bowels

• B: bones

• C: calcification/contrast/catheters

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AXR: Systematic approach

• B: bowels

• 3-6-9 rule

• Small bowel 3cm

• Large bowel 6 cm

• Cecum 9cm

• Small intestine: plicae circulares; centrally located

• Large intestine: haustra; peripherally located; stool


• Portal venous gas vs pneumobilia

• Portal venous gas: Peripheral

• Common bile duct gas: Central

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• B: bones

• Pelvis

• Ribs

• Vertebrae


• C: calcifications, contrast, catheters

• Gallstones, renal stones

• Catheters, stents

• Piercings

• Vascular calcifications

• IV and oral contrast

• Surgical clips

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Outline




CT Basics

• The convention of CT

• Slices the patient into multiple 3mm cuts

• Scout film

• Axial/Transverse Plane

• Coronal Plane

• Sagittal Plane

• Contrast

• Window levels

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CT Basics

• You MUST know the anatomy in order to understand what you’re looking at

• Then you much be able to envision the anatomy in 3-D

• Solid organs are easier than intestine so start with those

CT Basics

• Axial/Transverse Plane

• Patient is laying down

• Head is behind the screen (away from you)

• Feet are in front of the screen (toward you)

• Right/Left anatomic position just like xray

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CT Basics

• Coronal Plane

• “Corona” is Latin for “crown”

• Coronal suture in neonates

• Patient is standing

• Back is behind the screen

• Front is in front of the screen

• Right/Left anatomic just like xray

• Still 3mm cuts

CT Basics

• Sagittal Plane

• “Sagitta” is Latin for “arrow”

• Patient is standing

• One side is behind the screen

• The other side is in front of the screen

• Front is screen left, Back is screen right

• Still 3mm cuts

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CT Basics

• Windows

• Default is ”abdomen”/soft tissue

• Choose based on what you’re looking for

• Lung, Bone, Brain, Liver, etc

CT Basics

• Contrast: Oral vs IV vs both vs neither

• For acute pathology, use both if possible, get more info

• Oral: definitely for obstruction, ileus, any process where you need to see the bowel

• Consider NGT if patient can’t tolerate PO

• IV: vasculature, inflammation, tumors

• Risk/benefit if AKI, contrast allergy, etc

• Neither: basic anatomy

• Abdominal wall hernias

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CT Basics

• You must look at THOUSANDS of CT scans to get comfortable

• Always look at the images yourself before reading the report

• Scroll through quickly, then go back and focus on specific areas

Radiography: Systematic Approach

• Always look at the images before you read the radiologist’s interpretation

• Don’t order a study unless the result will change your management

• Use a systematic approach so that nothing is missed

• Continue to ask questions and keep learning

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Questions?

Thank you for your time!

Questions/Comments/Feedback: [email protected]

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