Important terms used in imaging
X-ray radiography
Radio opacity:A structure which appeare on radiograph is radio
opaque.It is because of more attenuations of x-rays by that
structure.
Radio lucency:An area or structure which appear more black
copared to adjacent structures is called lucent.It is because of
morre trnsmission of x-rays through that structure.
Ultrasound.
A structure which appear on white ultrasound is echogenic and this is because of attenuation of sound
waves through that area.
Hypo echoic.
Any part or tissue in the body whiich appear more black on ultrasound is hypo ecoic and it is because
of through transmission of sound waves through t5hat part of the body
CT scan
Hyperdense .CT image is described in term of densities.a white area in the image is hyperdense.
Hypodense:a black area appeare is hypodense
Any abnormal area in a structure which has same grey scale appearance is isodense
MRI
MRI image is described in term of intensities.white area in the mri image is hyper tense.
A black area in the image is hypointense
An abnormal area of the same color is iso intense
Nuclear medicine.These images are described in term of uptake
More uptake in an area is hot less uptake in an area is called cold.Or we called these areas are of high
uptake or low uptake
Normal X-Ray chest
1:Request form:
2:Technical aspect:
Check name age gender of tpatient.
Check date and time of examination
Check if any previous x-ray
Check clinical information
Projection PA or AP
Position: Upright or supine
Orientation. check side marker as there
May be congenital anomaly like
Dextrocardia.
Centering and rotation. Medial end of
the calvicle should be equidistance from the spinous process
Penetration. Vertebral bodies and disc
spaces should just be visible through the cardiac shadow.
Portable (AP or Antero-posterior)
FILM
007
PA (Postero-anterior)
FILM
008
Projection
PA
AP
009
Low Lung Volumes
010
Over Exposure
011
Proper Exposure
9
012
013
Clinical and x-ray manisfestations
• Seropositive rh factor is present in blood
• Goint pain,fever,weight loss etc
• Soft tissue swellings spindle shape of
interphalengeal joints
• Osteoporosis
• Joint space changes and alignment deformities
• Periostitis
• Erosions
• Secondry osteoarthritis
Exposure factors:
If the vertebrae and disc spaces are clearly
visible then over exposure
If they can not be seen it means the film is under
expose.
Over expose film will appear black and under
expose film will appear white.
Inspiratory efforts:Count the number of ribs
above the diaphragm.
*If 10 posterior rib is above the diaphragm---------adequate
*If 6 anterior rib is above the diaphragm ----------adequate
*If more ribs are visible above the diaphragm-----Hyperexpanded
lungs
*If less ribs-----------------------------------------------poor inspiratory
efforts
Look angles clear or not ,lungs bases clear or not.
3:Review of anatomy:
1.look at the heart.Asses the outline.Apex is
directed to the left or right.Look at the size.It should be 50% of
the thorax in adult and 60% in children
016
017
RUL (Right Upper Lung)
018
RML (Right Middle Lung)
019
RLL (Right Lower Lung)
020
Right Sided Fissures
021
LUL (Left Upper Lung)
022
LLL (Left Lower Lung)
Al-Yami
023
Left Side Fissure
LUL
LLL
024
Border of the heart:Right border---RT atrium
Left border ---Lt ventricle
Front
----Rt ventricle
Base
Lt atrium
Apex
Lt ventricle
Look at the cardiophrenic angles
Look at the mediastinum.It should form one third of the thoracic diameter.
Look at the hila.The left hilum is about 2.5cm higher than the right.
The hila should be of equal density and size.They should be concave in shape.
Look at the lungs field.
Examine the lung fields zone by zone and compre the two sides.Look also for the
fissure and lobe.
There are three lobs and two fissure on the right. The fissures are horizontal and
oblique.
There is only one fissure and two lobe on the left.
Look at the diaphragms.The right is higher than the left .It is because the heart apex is directed to the left.The
difference between the two side is 1,5cm if it is more than this it is abnormal.Costerphrenic angles
should be clear and sharp.
In a good inspiratory film, the diaphragm should be at the level of
10th posterior rib
6th anterior rib
Look at the trachea.It should be cebtral with slight deviation to the right.
It divide at the level of T4/T5 in to rt and lt main bronchus.The rt bronchus is shorter and wider than the
left.The left is longer and narrower.Tracheal division is called carina.The angle of carina is 65 to 70
degree.
Look at the bones.The density of bones should be similar on both sides
Look at the soft tissue of the chest wall
Look at the hidden areas. They are clearly in the LA view.
The hidden areas are
Retrocardiac,retrosternal,costopherinic and cardiopherenic angles apices,lung bases and hila and domes of
diphragm
Rhumatoid arthritis
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Autoimmune inflamatory disease
Occre in adults
Multisystemic disorder
Seropositive arthritis
Mainly affect the small joints of the hands and
feets
• Cervical spine and rarly large joints are also
affected,specially atlantoaxial and shoulder joint
Invistigations
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X-ray
Ultrasound
CT
Radionuclide studies
MRI
Psoriasiatic arthritis
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Seronegative arthritis
Affect the small jpints of hands and feet
Nail changes and skin
Affect and distal interphalangeal goints
Affect the spine with syndesmophyte
formation
• Sacroillitis
Reiters disease
• Syndrome of arthritis,urethritis and
conjunctivitis
• Affect the feet more than the hands
• Painfull erosion of calcaneus with spur
formation
• Sacroillitis
Ankylosing spondylitis
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Seronegative arthritis
HLA –B27 is positive
Affect young adults
Mainly affect the spine with chacteristic changes
Squaring of vertebral bodies and bamboo spine
Sacroillitis is bilateral and symetrical.sacroillic
joints are assesed with prone view of sacroilliac
joints
Gout
• A metabolic disease with abnormality of uric
acid
• Affect the great toe of feet
• Bone erosions
• Osteoporosis
• Tophi formation
Osteoarthritis
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Degenerative disease
Affect mainly the weight bearing joints
Primary when no cause is known
Secondry when the goint is abnormal
Mainly affect old people
Main complain of patient is pain and stiffness
More common in over wight people
X-ray appearences
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Joint space narrowing
Increase bone density
Osteophyte formation
Loose body
Cyst formation
Vacuum phenomenon in the intervertebral
spaces
Invistigations
• X-ray
• CT scan
Spondylolisthesis
• When there is slip of one vertebra over
another
• Usually occure due to stress fracture in the
parse
• Four grades
• 25%
• 50%
• 75% AND TOTAL
OSTEOPOROSIS
• Due to decrease bone mass
• Decrease bone mass result in increase incidence
of fracture
• Senile osteoporosis occue in old people.there is
loss of cortical and trabecular bone.Fracture
occure more commonly in femoral neck and
humerous
• Postmenopausal osteoporosis.occure in
womenabove 50 years of age.vertebral fractures
are more common
Rickets
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Vitamin D defficency disease
Occure in childern
There is lack of mimeralisation of bones
Lack of vitamin D
Lack of calcium
The above defficiency may be either
nutritional or disease process
X-ray appearences
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Loss of normal zone of proviosnal calcification
Fraying of growth plate
Splaying cupping of metaphysis
Osteoporosis
Pigeon chest
Rickety rosy
Osteomalacia
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Vitamin defficency disease occure in addults
More common in females
Bone become soft so bowing occure
Looser zones bilateral and symetrical
Compression of vertebrae
Cordfish vertebra
Tumors of bones
• Classification
• Two groups
1:primary 2: Secondary
tumors. Primary are divided in to a) benign
and malignant
• Primary bone tumors
• A: Benign 1.bony island 2.osteoma.3.osteoid
osteoma 4 osteoblastoma
• B: Malignent .Osteosarcoma
Cartilage tumors
• A. Benign 1.osteochondroma
2.chondroblastoma etc
• Malignent: chondrosarcoma
Tumors arising from other bone tissues and
tumor like condition.
• 1:Gaint cell tumors
• 2 : Aneurysmal bone cyst3:hemangioma
• 4:Ewing sarcoma 5:
Osteoid osteoma
• Benign bonr forming tumor.small in size with a
lucent central nidus .Give pain at night and
only releived by asprine
• Osteoblastoma. Same as osteoid osteoma but
larger in size and pain is not releived by
asprine .both these tumors occure in young
adult
Malignent tumors of bone and
cartilage
• Osteosarcoma.Occure commonly in childern
causing bone destruction,soft tissue and
mrtastasis
• Chondrosarcoma: Malignent cartilaage
tumor.more common in old people cause
destruction of cartilage,soft tissue mass with
calcification and metastasis in advance cases.
Ewing sarcoma
• Special bone tumor.More common in childern
causing bone erosion and clinical and
radiological appearences are like bone
infection
Neuropathic or charcot goints
• Causes are DM,syphilis and other
neuropathies.There is denervation of the
involved goints and loss of pain sensations
• X-ray appearences. Bone destructionincreased bone density-debries in jointsdisorganization of joints.
Osteomalacia
Ricket
Charcot,s joint
Ricket in a child
Respiratory system
Pulmonary tuberculosis.
• It is an infectious diseas caused by mycobecterium
tuberculosis.
• It mainly involve the lungs,although it can affect any
organ in the body.
• Two groups 1:Typical 2:Atypical
• Typical are Mycobecterium tuberculosis and M,bovine
• Atypical are-M,avium intracellulare.M,kansasi
• And M,xenapi etc
• Disease is common in poor class,alcoholics and aids
patients
Primary tuberculosis
• Usually heals with out complications
• Sequence of events includes
Consolidation
Caseation
Lymphadenopathy
pleural effusion
Spread of primary occure in childern and
immunosupressed.
Complications
Milliary TB,pleural effusion
pneumothorax
tuberculoma
bronchopleural fistula
Atypical TB
• Caused by atypical organisms as mentioned
above
• The presentation may not be distinguished
from fron typical
• Treated by second line of drugs
Post primary or secondry tubercolosis.
• Common in adults,usually occure as
re,infection.
• Common in apical segments of upper lobes.
• Features includes.
patchy consolidation
cavitation
fibrosis
calcification
X ray chest shows T.B in both lungs field
Milliary TB
PA view chest
AP view chest
• Routine view of chest
• PA is usually done in errect
position
• Cassete is in front and X-ray
source is behind
• PA view minimise cardiac
magnification
• PA is sharper,lungs fields
appear clear
• Lungs bases CP and
cardiophrenis angles are clear
• Usuallu done in emergency
• It is done in supine position
• Cassete is behind and x-ray
source is in front
• Heart and mediastinum
appear enlarge
• The closer structure to the
image source appeare enlarge.
• Lungs fields are not as clear as
PA view
PA
• Scapullae are removed from
lungs fields.
• Ribs appear more horizontal
• PA is easy to read
• It is easy to lower the
diaphragm in PA
AP
• The scapullae is projecting
over the lungs fields.
• The ribs appear more
vertical
• AP is difficult to read
• There can be 15%
difference between width
of mediastinum in AP and
PA
Some definitions
• Radiolucency.The area which appear black on the
X-ray.It is because of through transmission of xrays through that part.
• Radiopacity.Such area appeare white on the xray.It is because of more attenuation or
absorption of x-rays.eg pneumonia,bony
structures
• Consolidation.The replacement of air in the lungs
by fluid without any change in lungs volume is
consolidation.eg pneumonia etc
Cont definitions
• Dextrocardia.Abnormal position of heart in the RT hemithorax with
the apex pointing to the right.It occure with transposition of viscera
or some time with out transposition.
• Pneumomediastinum.Air in the mediastinum.the causes are
infection,trauma and tumors
• Silhouette sign.When there is loss of interface between lungs and
adjacent structures eg heart and diaphragh.It help in the
localization of lungs pathology.Heart and lungs are normally seen
because there is adjacent aereated lungs.When air in the adjacent
lungs is replaced by fluid,these borders are no longer seen.
• Hilum overlay sign.It differentiate between enlarge heart and
mediastinal mass.
• Cervicothoracic sign.A welldefined mass seen above the clavicle in
the lungs is always posterior wheae as anterior mass is in soft tissue
and is not welldefined.this is cervicothoracic sign.
Pneumonia.
• It is an inflamatory reactions in the lungs.
• Primary pneumonia.inflamation occure in normal
lungs.
• Secondry pneumonia.Inflamation occur when
there is occlusion of bronchus eg tumors or
foreign body.
• Lobar pneumonia.When pneumonia is confined
to one lobe cause by streotococcus pneumoniae.
• Bronchopneumonia.When there are bilateral
multifocal areas of consolidations
Types of pneumonias
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Viral-common in childern
Bacterial –eg streptococcus etc
Mycoplasma-Atypical pneumonia
Legionella pneumonia.rapidly progressive
pneumonia
• AIDS.Pneumocystis carani pneumonia.
• Radiation pneumonia.consolidation in the
field of radiation
Radiological features of pneumonia
• Because of inflamation air in the lungs is
replaced by fluid which may be confined to
one lobe(lobar pneumonia) or multifocal in
one or both lungs field( bronchopneumonia)
• There may be associated pleuraleffusion.
Pneumothorax.
• Collection of air in the pleural cavity is called
pneumothorax.
Causes.Spontaneus
Trauma
Iatrogenic
Pre-existing lung disease.
Radiological features of pneumo-• Best demonstrated by underpenetrated and expiratory
film
• The area appeare lucent .
• There is underlying lung collapse
• Absent lung marking between lung edge and chest
wall.
• Lung edge .a thin white line of lung margin is seen, the
visceral pleura.
• Mediastinal shift is seen when there is tension
pneumorax.Tension pneumothorax is an emergency
and treated by lung entubation.
Treatment of pneumothorax
• Small pneumothorax usually require no
treatment.large pneumothorax is generally
treated by putting a tube in the pleural cavity
with an under water seal, follow up film are
required .
Pleural effusion
• Collection of fluid in the pleural cavity.It is usually
serous fluid.
• Haemothorax.If the fluid is blood-common in
trauma
• Chylothorax.If the fluid in the pleural cavity is
lymphatic.common in malignent tumors
• Empyema.when the fluid in pleural cavity is puscause is infection
• Hydropneumothorax.When both air and fluid
collect in the pleural cavity
Type of pleural effusions
• Free pleural effusion.It is free to move and
gravitate to the most dependent part of the
lungs
• Encysted pleural effusion.
• Lamillar pleural effusion.Along the chest wall
• Subpulmonary .Between the diaphragm and
inferior surface of the lungs
Radiological appearance of PL effusion
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Fluid appear radiopaque
First there is blunting of costopherinic angles
There is loss of diaphragmatic and cardiac outline
When the fluid increase in volume it assume a
crescent shape
• Further increase of fluid opaque the whole
hemithorax if effusion is unilateral
• There may be shift of mediastinum or underlying
lunf collapse
• Treatment is by intubatation and aspiration
Cavitating lesions in the lungs
• Causes.Infection,tumors,trauma and congenitial
lesions.
• Abscess formation within cosolidated area of lung
occur due to becterial infections.some organism like
staphylococci produce cavity.
• Cavity also occure due to tumors.
• Malignent tumors produce thick wall cavity
• Tha inside of the wall may be nodular in malignent
lesion but smooth and thin in benign lesion.The cavity
may contain fluid,but if it communicate with
bronchus,air fluid level is produced in the cavity.
Bronchiactasis.
• Irreversable dilation of the bronchi is called
bronchiactasis.There my be impairment of
drainage which may lead to secondry infection
• Presentation.Cough with purulent sputum.
• Causes.Childhood infection
Fungal infections
Bronchial obstruction
Cogenital.Kartagners syndrome.
Bronchiactasis
Emphysema
• Emphysema is chronic lung disease in which
there are over inflation of the air spaces
specially the alveoli with destruction of its wall
• The patient present with shortness of breath
• It is common in old people
• It usually occur with other lung diseases
specially chronic bronchitis.
• It can be congenital and occur in infancy
Emphysema
Radiological appearences
• The chest x-ray may be entirly normal
• Cylindrical.Dialated bronchi may be visible as
parallel lines.
• Cystic.dilated bronchi may be visible as cysts.
• Pneumotic consolidation
• Fibrotic changes.
• Complications are empyema,cerebral abcess.
10 radiological views for chest
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PA view in full inspiration
PA view in expiration for pneumothorax
LA view chest
AP supine
AP errect eg when patient has khyphosis
Apical view
Apical lordotic view
Oblique views
Lateral decubitius view
Lordotic view To demonstrate middle lobe collapse
Lungs tumors
• Primary and secondry
• Primary is divided in to benign and malignent
• Benign are adenoma,hamartoma and
carcinoid
• Mlignent.bronchogenic carcinoma,sarcoma
lymphoma and metastasis
Brongenic carcinoma
• Commonest malignent tumor of the lungs occur
commonly after the age of 50 years
• More common in male and smookers
• Clinically present with cough,sputum,shortness of
breath,chest pain and hemoptysis.
• Radiological sign are.
• Peripheral mass
Bronchogenic carcinoma
• Mediastinal lymph node enlargment
• Cavitation and consolidation
• Carcinoma in the apical region is called
pancost tumor.
Abdomen.
• Acute abdomen is an emergency.
• Causes of acute abdomen
Acute intestinal obstruction
acute pancreatitis
acute appendecitis
acute cholecystitis
renal colic
acute slphangitis
ovarian torsion
trauma etc
Radiographic technique acute
andomen
• 1:x-ray chest PA view in errect position
• This view is important for the detection of
pneumoperitoneum especially on the RT side
between the liver and diaphragm.
• Abdomen errect.This film show fluid level in the
abdomen.
• Supine abdomen.This the pattern of distribution
of gas in intestine
• LA abdominal view.This help in detection
calcification in aorta and also differentiate
calculus from calcified lymph nodes.
Radiographic tachniques
• La decubitus film.RT and LT lateral decubitus
film help in the detection of
pneumoperitonium.The technique is put the
patient in the left lateral position with rt side
up for 10 minutes and take a horizontalray
film.This technique detect small
pneumoperitoneum.It can also detect small
amount of ascites when fluid collect in the
dependent part of abdomen.
Pneumoperitoneum
• Collection of air in the peritoneal cavity
• Causes.1.perforation of gastric ulcer
2.perforation of other viscus
3.post operative
4.post operative
5.post embolization
6.peritonitis
7.perforated appendecitis etc
Errect chest shows
pneumoperitoneum
Radiographic appearances of small and
large intestine
Small intestine
• Vulvulae connivente are
present
• Many loops are present.
• Loops are distributed in the
centre
• Haustra are absent
• Diameter is 3-5cm
• Radius of curvature is small
• Solid faeces absent
• Length is about 6 meter
Large intestine
• Volvulae conniventes are
absent
• Few loops are presents
• Loops are distributed in
periphery
• Haustra are present
• Diameter is 5cm+
• Radius of curvature is large
• Solid faeces present
• Length is 1.5 meter
Small intestine
Large intestine
Intestinal obstruction
• Dynamic obstruction.due to tumor,stricture or
extrensic compression by a mass
• Adynamic obstruction.It is also called paralytic
ilius.causes are peritonitis and postoperative
• Clinical
presentation.Pain,distension,tenderness,vomit
ting and absolute constipitation
Intussusception
• When one segment of the intestine prolapse in to
the adjacent of the intestine.It is common in
childern at the age of 2 years but also occur in
adult.the causes are tomor ,enlarge lymph nodes
etc.
• The clinical features are colicky abdominal
pain,vomitting and bloody diarrhea.
• Plain film show a mass in the proximal bowel and
contrast study show a coiled spring appearance.
The management is either reduction
by contrast enema or surgery