Radiology – An Introductory Guide
Lidia Baiocchi
Radiology – An Introductory Guide ................................................................................... 1
1 Introduction ...................................................................................................................... 2
2 Anatomy – Left and Right Heart Border ......................................................................... 3
3 Anatomy – Lungs ........................................................................................................... 11
4 Radiology – Mediastinum .............................................................................................. 16
5 Radiology - Chest with Emphasis On Surgical TB ....................................................... 20
6 Radiology – Volvulus and Colon ................................................................................... 29
7 Radiology – Chest Trauma ............................................................................................ 41
8 Radiology – Dynamic or Paralytic Ileus? ...................................................................... 45
9 Radiology – UGI ............................................................................................................ 48
10 Radiology - Urology .................................................................................................... 65
11 Radiology – Paediatric ................................................................................................. 74
12 Surgical Emergencies in the Newborn ......................................................................... 79
Creative Commons Attribution License
1
1 Introduction
The X-rays contained in this booklet have been collected from the Hospital Central de
Beira and represent ordinary patients you might happen to see during your rotations now
and in the near future. Most of the images you see here, you will never find in regular text
books and this is the motivation for this short booklet.
Some images are discussed in detail, others are just displayed and a few images of
patients are included to try and give you a better understanding. Some illustrations
attempt to reflect the basic principles of how a disease process works.
This small collection has been possible thanks to the paediatricians who have supplied
many interesting cases, to radiologist Dr Pietro Sergio in Italy who has corrected the
report of the X-rays we have sent to him and to many 5th and 6th year students who have
annotated them.
Some of these X-rays have been discussed with the students, Dr. Italo Turati and myself
during Thursday morning 11 o’clock sessions. This time has become an enjoyable
experience when it became clear that there would be no notes or assessments but only the
pleasure to translate some bi-dimensional images into a real three dimensional patient
with problems.
If some of you are deciding to specialise in radiology in the future, please feel free to do
whatever you wish with this booklet and its images. They are yours.
2
2 Anatomy – Left and Right Heart Border
Angiographic image of Pulmonary arteries using contrast medium
Fig 1
Fig 3
Fig 2
Fig 4
In Fig 3 the contrast medium is in the aorta and its branches. In Fig 4 numbers 1-2-3
position the first, second and third ribs. ARD = Rt Pulmonary artery, APE = Lt
Pulmonary artery, BG = gastric bullae
3
Below is a Bronchogram due to aspiration of barium in this case of carcinoma of the
oesophagus. This should be avoided!! Always ask the patient if she/he coughs after
drinking some water. If in doubt, proceed with IV contrast medium
Fig 5
Fig 7
Fig 6
Fig 8
As you can see from the X-ray with barium, the patient has aspirated some of the barium
from the oesophagus into the bronchial tree. You can observe that the left lower lobe is
descending below the dome of the diaphragm (Fig 8) and just a trickle of barium is going
into the stomach.
4
Fig 9
Fig 10
Fig 9 displays the microscopic view of alveoli and their blood supply. Fig 10 reflects the
microscopic view of the capillary-alveolar relationship. Remember that in pulmonary
oedema, only water exists between alveolar and the capillary surface and this is enough to
cause the death of a patient. Realize what can happen when, for example in diabetes, a
thicker substance is deposited between capillaries and body tissues.
Right heart border
Fig 11
Fig 12
Thorax = PA view. SVC = Superior Vena Cava. A = Aortic Arch. PA = Pulmonary
Artery. LA = Left Atrium. LV = Left Ventricle. RV = Right Ventricle. RA = Right
Atrium
5
On the left (Fig 13) is a pulmonary artery angiography and on the right (Fig 14) the image
of a trachea and a calcified aorta
Fig 13
Fig 14
Familiarize yourself with the normal anatomy each day and attempt to locate each organ
that should be present on your Xray. This exercise will teach you a lot and establish a
method that will assist you in not overlooking something in the future.
Fig 15
Fig 16
(We start with some x-rays sent to Dr. Pietro Sergio and his corrections appear in bold
print. The x-rays are displayed first, followed by our description and then Dr. Sergio’s
correction in bold print)
6
Right and left lung parenchyma reach below 11th rib.
“Good bilateral parenchymal expansion”
Both upper lobes contain large bullae, three on the left and one on the right.
Evidence of small caverns at lower right lobe.
OK
Upper lobe parenchyma collapsed by bullae?
When bullae are present, it means that there isn’t parenchyma so the bullae, as in
emphysema, cannot produce atelectasis
Scissuritis at right and pleural effusion localized at upper right lobe.
Pleural effusion as well at upper left lobe.
Bilateral effusion at right upper lobe and right costophrenic angle.
Pleural effusion at both upper lobe and lower lobe on left side with occupied costophrenic
angles.
Bilateral effusion, coexists localized effusion in minor fissure on right. In the third
upper of left hemithorax it’s documented a radiopaque sub pleural area, with thick
mass of... (Localized effusion? solid pleural thickening?)
Lung vasculature normal.
Slight, right shift of trachea.
Fig 17
Pneumothorax due to (that determines) partial collapse of left upper lobe.
Visceral pleural thickening at upper lobe (according to me unremarkable).
Loss of cardiac silhouette on the left side due to lower lobe parenchyma consolidation.
Obliterated costo-phrenic angle with (due to) air fluid level for a localized empyema.
In the lower third of the left hemithorax it’s documented a wide radiopaque area,
it’s associated a pleural air-fluid level; these data are consistent with pleuropneumonia.
7
NOTE: I have interpreted the air-fluid level as pleural, as you have suggested,
nevertheless the hypothesis of a parenchymal excavated lesion may not be excluded,
and therefore the diagnosis would be parenchymal abscess and pleurisy.
Right lung parenchyma normal, acute costo-phrenic angle.
Lung vasculature normal on right side (no signs of oedema bilaterally).
Distal extremity of chest tube on left side.
Fig 18
Fig 19
Hyperinflated lungs bilaterally. Left side normal, acute costo-phrenic and cardio-phrenic
angles. On the right side Fig 22 hilar vacuolated mass and distal to its area of parenchyma
consolidation. Cardio-phrenic and costo–phrenic angles normal. Peri-hilar caverns.
OK
8
8 Fig 20
Normal left lung parenchyma, on the right side scissuritis and a sail sign at the diaphragm
pathognomonic of pulmonary TB. Both costo-phrenic angles occupied, cardio-phrenic
angle at right side not evident. Mediastinal structures normal.
Fig 21
Right parenchyma clear, with hypertrophy pushing heart to the left. Clear costo-phrenic
angle on the right. On the left side we have two sacculated collections of liquid and
collapse of the left lung. Lung parenchyma is not visible on the left side. Ribs fall on each
other and chest cavity is much smaller than right side. Heart shadow is not visible
9
meaning that close to heart border there is a collection of fluid with similar density and or
collapsed left lung parenchyma.
DISEGNO DELLE COSTE CHE CADONO UNA SULL’ALTRA
10
3 Anatomy – Lungs
Fig 1 shows a representation of areas corresponding to the different lobes and their sublobar units. Fig 2 shows the anatomical subdivisions of the bronchial tree.
11
Fig 3a RUL pneumonia with air bronchogram Fig 3b RUL segmental consolidation
Right lung parenchyma: RU lobe consolidation with air bronchogram. R middle lobe
with consolidation of superior segment and lower lobes normal. On the left, normal lung.
Costo-phrenic and cardio-phrenic angles normal bilaterally. R and L acute costo-phrenic
angles. Heart size larger than half costal-to-costal margin.
Fig 4
Collapse of right lung with fibrous adhesion between collapsed parenchyma and lateral
chest wall (arrow) preventing a hypertensive pneumothorax due to a ruptured sub-pleuric
cavern and therefore a broncho-pleuric fistula. The adhesion between the remaining lung
and the wall is the result of old TB which created a fusion between parenchymal and
parietal pleura (arrow). Note the shift to the left of cardiac shadow and the compression
12
exerted by the localized hypertensive pneumothorax on the right diaphragm and liver.
Heart shadow enlarged.
Fig 5
An old tubercular cavern filled by Aspergillus flavum. Sometimes the fungus ball in the
cavern becomes symptomatic and can produce haemoptysis. Note the difference between
the right and the left hemithorax. The right site has hypertrophied while the left side is
contracted and shows another sign of TBC with the tenting of the diaphragm denouncing
an adhesion between lung parenchyma and diaphragm (sail sign).
-----------------------------------------------------------------------------------------------------------Silhouette Sign - Cardiac margins are clearly seen because there is contrast between the
fluid density of the heart and the adjacent air filled alveoli. When two structures have the
same density (right and left ventricle), you cannot visualize the partition because there is
no contrast between them. If the lung adjacent to the heart is devoid of air, the clarity of
the silhouette will be lost. The silhouette sign is extremely useful in localizing lung
lesions. To utilize the silhouette sign you must know what structures are adjacent to each
silhouette.
Silhouette
Right diaphragm
Right heart margin
Ascending aorta
Aortiv knob
Left heart margin
Left diaphragm
13
Adjacent Lobe/Segment
RLL/Basal segments
RML/Medial segment
RUL/Anterior segment
LUL consolidation
Lingula/Inferior segment
LLL/Basal segments
fig 6
fig 7
fig 8
fig 11
fig 10
fig 9
You should know that the pleura encloses the lung and diseases of the pleura can also
obliterate silhouettes. The same is true for mediastinal masses.
Fig 6 RUL
Fig 7 RML
Fig 9 LLL
fig 10 Lingula consolidation Fig 11 LUL
14
Fig 8 RLL
Main fissure on the right is frequently visible due to accumulation of fluid and the most
frequent cause of fluid formation is TB.
ANATOMY OF A LATERAL VIEW
Fig12
A= oesophagus, B = trachea, C = pulmonary hylum, D = heart,
E = lung apex, F = scapula, G = vertebra, H = intervertebral foramen,
I = rib, J = costo-phrenic angles, arrows SHOW diaphragms.
15
4 Radiology – Mediastinum
Fig 1 Yellow anterior, blue posterior,
Pink middle mediastinum
Fig 2 mediastinal divisions on X-ray
MOST FREQUENT PATHOLOGY IN MEDIASTINAL COMPARTMENTS
ANTERIOR
YELLOW
SUBSTERNAL THYROID GLAND
THYMOMA
TERATOMA
LYMPH NODES
LYMPHOMA
MIDDLE
PINK
VASCULAR aneurysms, enlarged heart
LYMPH NODES lymphoma, metastatic cancer
OESOPHAGEAL achalasia, diverticula
BRONCHOGENIC OR PERICARDIAL CYSTS
POSTERIOR NEURILEMMOMA
BLUE
NEUROFIBROMA
GANGLIONEUROMA
> 1 COMP
INFECTION
HAEMORRHAGE
LUNG CANCER
16
Fig 3 Left lateral view
Fig 5 mediastinal mass
Fig 4
Right anterior oblique view
Fig 6 - pneumopericardium
QUESTION: is the mass mediastinal or does it affect the nearby lung or pleura?
QUESTION: does the mass have anything to do with heart?
ANSWER: request a lateral or an oblique xray and administer some barium via the
oesphagus.
Mediastinal lesions can cause:
- Pneumo-mediastinum (air coming from the oesophagus e.g a perforated
carcinoma of the oesophagus).
- can alter the position of the oesophagus
- So remember, do request a barium swallow to eradicate all doubts.
17
Lung parenchyma is normal on the left side. On the right side, there is a reduction of the
right lung. One cavern is visible in the upper lobe. On the right side a large thickening of
scissure, multiple nodes at the ain right bronchus division. Lower lobe with similar
thickening of parenchyma. Pleural space normal on the left side with acute cardiophrenic
angle. On the right side cardiophrenic angle occupied, thickening of pleura at upper lobe
level and lower lobe level. Lung vasculature normal on left side and not clearly visible on
right side due to multiple hilar densities. Mediastinal structure shows a large round mass
both on right and left side representing a mediastinal tumor.
Mediastinal anatomy
18
Thymoma
Mediastinal tumor middle
Superior vena cava syndrome
19
Air fluid level in posterior chest cavity
5 Radiology - Chest with Emphasis On Surgical TB
Fig 1
Fig 2
Fig 3
Fig 1, 2 and 3 show the evolution of a complicated pulmonary TB. In Fig 1 a sacculated
empyema with an air-fluid level. In figure 2, after surgical drainage of the left chest and
removal of part of the empyema fluid, several sacculations are evident. Obliteration of the
lower cardiac border and diaphragm. In figure 3 the end-result. Destroyed pulmonary
parenchyma on the left, Adhesion of the lung to the L apex and destruction by TB of the
20
left lung. Most of the left lung is destroyed. TB must be confirmed or ruled out. TB must
be treated to prevent further damage to the rest of the lung.
Fig 4
Fig 5
What is the difference between fig 4 and fig 5? In Fig 4 we have an air fluid level and
purulent fluid accumulation from a ruptured cavern into the visceral pleura. Previous sub
pleural tuberculous granulomas have created adhesions between visceral and parietal
pleura. This is preventing total lung collapse In Fig 5 we have a lower lobe pneumonia
confirmed by the loss of cardiac silhouette on the right side. Anatomy helps to determine
the difference between pneumonia and pleural fluid collection.
Fig 6
Fig 6 displays a tension pneumothorax. This is caused by a lesion of the parenchyma and
overlying pleura with a flap mechanism. Air escapes into the pleural space and cannot
21
return to the bronchial tree. With each inspiration air pressure increases in the pleural
space and this air is then able to shift mediastinal structures to the opposite site. Vena
cava return is affected and death can ensue. Hypertensive pneumothorax is a surgical
emergency. The most frequent causes are trauma and tuberculosis.
LOOK AT THE RIBS: dropping ribs on one side are generally a sign of disease,
look for it
Fig 7
Asymmetry of lung parenchyma (left>right) with shift of trachea to the right side due to
overinflated left lung. (Compare ribs between right and left, left are almost horizontal,
right are dropping). Right lung parenchyma shows more diffuse densities and one cavern.
Pleural space normal on left side with acute costophrenic angle. On the right side marked
distortion of diaphragm due to TB adhesion between pleura and lung (sail sign, arrow),
right costophrenic angle free. Left lung vasculature normal, not clearly seen on right side.
Cardio-phrenic angle normal on the left side and on the right side.
Fig 8 (a, b)
22
Left lung shows partial lung collapse with hypertension. This time the horizontal ribs are
abnormal! Shift of trachea and heart to the right. Multiple adhesions mainly at upper lobe
level prevent total lung collapse. Right lung displays multiple round infiltrates. Pleural
space on the left side shows signs of hypertension, flattened diaphragm with an air-fluid
level. On the right side, there is an acute medial diaphragmatic angle and an occupied
costo-phrenic angle.
Two sail signs are visible, on two different planes between diaphragm and lung
parenchyma on right side. The lung vasculature is not visible on the left side. Both the
heart and trachea are shifted to the right. Next, fig 8b shows further detail of the two sail
signs. Sail signs are old fibrotic adhesions between diaphragmatic pleura and visceral
pleura pathognomonic of TB.
One ICU patient, male, 74 years old, in acute respiratory distress, after insertion of
a chest tube (even with a kink) the lung expanded, fluid was drained and you can see
in Fig 10 a partial pneumothorax on the right side, successful drainage of the large
empyema on the right and drainage as well of the sacculated lateral empyema.
In Fig 10 the lateral sacculated fluid collection has not yet been treated.
Fig 9
Fig 10
In Fig 10, the sacculated empyema is still present in the left lateral chest wall. This was
aspirated with a syringe and yielded 350 cc of purulent liquid.
MECHANISM OF PULMONARY TB PATHOLOGY
INHALATION OF TBC BACILLUS
Formation of a lung implant if defenses not appropriate. Formation of a reaction to
invader: tubercle. Tb bacillus can be dormant in tubercle and can later reactivate.
Encapsulation not successful or later reactivation: tissue invasion, central portion of
tubercle with cellular necrosis, wall erosion into adjacent structures (bronchi or parietal
pleural).
23
If invasion into bronchus, cough and sputum and reinfection of other areas. If invasion
into parietal pleura empyema. If infection adjacent to parietal pleura pleural effusion.
Often effusion precedes empyema.
Fig 10
24
In Fig 10 we see a marked asymmetry between the right and left hemithorax. Ribs are
dropping on the left side, there is an air fluid level and a complete collapse of the lung
Fig 11
Miliary tuberculosis on the left side
Fig 12
Left atrial enlargement demonstrated with barium
Fig 12
Where to find trachea on lateral
Which is right diaphragm? A or B?
Why? Teh right diaphragm is generally 2 cms higher than the left one because of the
dome of the liver. The trachea is very evident on this X-ray and you should know where
the oesophagus is positioned: it is just posterior to the trachea up to the bifurcation. After
this it follows the heart shape and is used to diagnose left atrial enlargement (see Fig 12)
25
Fig 13 (a, b)
Right and left lung parenchyma extends below 11th rib.
Good parenchymal expansion bilateral
Both upper lobes contain large bullae, three on the left and one on the right.
Evidence of small caverns at lower right lobe.
OK
Upper lobe parenchyma collapsed by bullae?
When bullae are present, it means that there isn’t parenchyma so the bullae, as in
emphysema, can not produce atelectasis
Scissuritis at right and pleural effusion localized at upper right lobe.
Pleural effusion as well at upper left lobe.
Bilateral effusion at right upper lobe and right costophrenic angle.
Pleural effusion at both upper lobe and lower lobe on left side with occupied costophrenic angles.
Bilateral effusion, coexists localized effusion in minor fissure on right. In the third
upper of left hemithorax it’s documented a radiopaque subpleural area, with thick
mass of... (Localized effusion? solid pleural thickening?)
Lung vasculature normal.
Slight, right shift of trachea.
26
Fig 14
Fig 15
Pneumothorax due to (that determine) the partial collapse of left upper lobe.
Visceral pleural thickening at upper lobe (according to me unremarkable).
Loss of the cardiac silhouette on the left side due to lower lobe parenchyma
consolidation.
Obliterated costo-phrenic angle with (due to) air fluid level for a localized empyema.
In the third lower of the left hemithorax it’s documented a wide radiopaque area,
it’s associated a pleural air-fluid level; this data is consistent with pleuropneumonia.
27
NOTE: I have interpreted the air-fluid level as pleural, as you have suggested,
nevertheless the hypothesis of a parenchymal excavated lesion may not be excluded,
and therefore the diagnosis would be parenchymal abscess and pleurisy.
Right lung parenchyma is normal, acute costo-phrenic angle.
Lung vasculature is normal on right side (no signs of oedema bilaterally).
Distal extremity of chest tube on left side.
Fig 16
Fig 17
28
6 Radiology – Volvulus and Colon
A 34 year old woman is admitted over the weekend to the surgical department from the
emergency room displaying abdominal pain for 4 days. On Monday the patient improved
and we noted an infra-umbilical incisional hernia for a C-section done 3 years prior to
admission.
The woman is thin, apparently in good health and sero-negative. The surgeon requested a
barium meal on admission.
Fig 1
During ward rounds the patient is relaxed experiencing no pain, the abdomen is soft. The
patient has been booked for an incisional hernia repair. We requested another abdominal
X-ray to better understand the previous X-ray with contrast
29
Fig 2
The patient is ok, she is eating normally and has had regular bowel movements possibly
eliminating all residual barium. The new X-ray shows a faint shadow of barium still
sitting in the large dilated bowel loop we saw on the previous X-ray. Is this a latrogenic
volvolus of the ascending colon produced during the C Section?
We waited a further 4 days and requested another X-ray. The patient, in the interim, is in
a good mood and anxious to be discharged.
Fig 3
30
In conclusion: a coecal volvulus most likely getting on and off, as suggested by the shape
in right iliac fossa on the first X-ray. Sigmoid volvulus is common in Mozambique. They
appear in young males 27-30 years. I think in this case we have a complication caused
during the C/S earlier. In all 3 X-rays we observe a dilated loop.
Answer: The case is really interesting. In countries with a high fiber content diet
this pathology is common. I believe that the dilated loop is actually the coecum
which rotates on its axis around a main adhesion and opens and closes frequently. If
it had been a complete volvulus we would not possibly see contrast medium in the
coecum. We have a door through which contrast medium manages to reach the
coecum. As a matter of fact, in the first X-ray we see air fluid levels in ileum and
this favours the hypothesis that the dilated loop in the first image could really be the
coecum with volvolus able to twist and untwist representing a door through which
contrast medium gets through.
-----------------A young man was admitted and a plain erect abdominal X Ray (Fig. 4) displays a huge
distension of one bowel loop. The loop in question has a thick wall, pushes the diaphragm
cranially (remember the right is generally higher than the left diaphragm) and this is a
sign that the disease is not acute but acute on a chronic condition. It is called volvulus of
the colon and is very common in young males in Mozambique.
Fig 4
Fig 5
This is the barium enema of the same patient who was an emergency admission to the
ICU for a distended abdomen (fig4). He had a bout of diarrhoea soon after admission, his
abdomen flattened and a barium enema was requested in the following days.
31
Fig 6
Fig 8
Fig 7
Fig 9
In fig 7 we try to illustrate how the loops are positioned and that they can hide each other,
but the wire can help you to follow the colon from a rather high ileo-coecal valve down to
the sigmoid.
32
Fig 10
On the right side in fig 4 you can observe the ascending colon and a loop of the
transverse colon at the right flexure (this is better observed in fig 6 since there is a slight
rotation of the patient). So the colon here builds a loop which is attached to the mesentery
only in two points. In Fig 4 and 5, looking at the descending colon, we see another loop,
filled with barium, representing the sigmoid colon. Therefore, this patient should have
been admitted for resection of both loops to prevent further emergencies.
Fig11
Sigmoid volvolus is a common disease in young adult males in Mozambique. The basic
cause is an anatomically redundant sigmoid (sometimes a redundant transverse colon or a
mobile coecum). The patient is usually a young adult male and 97% of the time they will
present with acute abdominal occlusion.
33
As can be observed in fig 6, 7, 8, 9, 10 (colon study with barium) the transverse colon is
redundant as well as the sigmoid colon. At the base of the loop there is frequently fibrous
tissue.
Filling of this loop with liquid or semi-liquid faeces (diarrhoea) can prevent successful
peristalsis and we have an occlusion (at arrow level in Fig 10), gas formation, huge
distension and due to compression on small vessels, bowel wall anoxia which can lead to
necrosis, perforation and frequently, due to delay, death.
Fig 12
Fig 13
The mechanism of the formation of a sigmoid volvolus can progress to gangrene and
death. Note on the X-rays in Fig 4 and Fig 11 that the wall of the distended loop is very
thick. This means it has hypertrophied with time. This indicated that the patient has a
long history and the current problem should be considered as an acute episode in a
chronic condition. Preventive removal of the redundant loop is the best way to deal with
the problem. Knowledge of the frequency of the disease can keep medical personnel alert
and active.
34
TUMOURS OF THE COLON
Fig 14
Fig 15
A barium enema shows a distally filled colon with no irregularities of the left colon,
splenic flexure, transverse colon and distal part of right colon. The distal part of the right
colon shows a filling defect and wall irregularities in its most proximal part.
35
After partial evacuation the left colon, as well as transverse colon, show regular mucosal
pattern. The transverse flexure loop is not visible. The ascending colon shows filling
defects of different sizes and small irregularities of bowel wall. The filling defects of the
coecum do not change from previous image as well as in the next one.
Ok
The conclusion suggests several masses occupying the coecum which require further
investigation to rule out malignant or pre-malignant disease. Remember that Schistosoma
eggs cause bowel granulomas in their failed attempt to reach the lumen. Granulomas are
potentially dangerous because of intense proliferation and the possibility of malignancy.
Fig 16
TUMORS OF COLON (RIGHT SIDE AND LEFT SIDE)
Fig 17
36
Fig 18
Fig 20 (a, b)
The two sides of the colon have a different predisposition to colonic cancers. The right
side favours growing, vegetating tumors that bleed and produce anaemia and acute blood
loss, while the left side favours infiltrating tumours that cause constipation alternated
with diarrhoea and eventually occlusion. The typical image is that of an apple core.
Vegetative carcinoma of right colon
Infiltrative carcinoma of left colon
Malignant tumors are not very common in Mozambique but remember that
Schistosomiasis is frequently a cause of colonic tumors. The tumors arise in areas where
Schistosoma eggs (on their way out of human body) are trapped in the bowel wall and
with time produce tumors.
37
Hirschprung’s disease
Fig 21
The most common presentation of Hirshprung’s disease is a child around 5-8 years old
with a distended abdomen and a history of rare bowel movements. A plain X-ray
generally is enough to raise suspicion and refer the patient to a surgical unit.
Fig 22 (a, b)
This patient, a 20 year old female, had a very short segment and was only diagnosed at a
very old age.
ANORECTAL MALFORMATION
We describe some common paediatric images at the end of this guide. Here is an image
of a rare situation: an imperforated anus, a vesico-rectal fistula and bilateral
hydronephrosis.
38
Fig 23 Try to find out what happens here. The answer is near the end of the guide.
INTUSSUSCEPTION
Fig 24
39
Fig 25
Fig 26
Fig 27
Fig 28
Intussusception, relatively common in children, also appears in adults in Africa. It is
characterized by an abdominal mass, colic and diarrhoea.
Fig 29
Fig 30
Chilaiditi syndrome = colon above and in front of liver – this is a rare anatomical
variation and does not have pathological consequences, but it does exist in Beira in
Mozambique.
For childhood colo-rectal pathology see the PAEDIATRIC chapter.
40
7 Radiology – Chest Trauma
Ruptured diaphragm and diaphragmatic hernia
Fig 1
Fig 2
In Fig 1 an 8 year old boy, the 2nd son of four, stopped growing, became more sedentary,
his school performance worsened remarkably and his younger brother became taller than
him. Fig 1 shows part of the thoracic-lumbar column, a well defined right diaphragm
(arrow), a missing left diaphragmatic shadow and several air or contrast filled cavities.
The patient had received some barium per os and the diagnosis made was a ruptured
diaphragm and the herniation of the stomach into the left hemithorax.
Fig 2 shows a lateral view of the thoracic abdominal region of a newborn with respiratory
distress. The thoracic cavity is occupied by solid masses and air containing bowel. In this
case the diaphragmatic defect was congenital and not acquired.
41
Fig 3
Fig 4
Fig 3 shows what a flail chest is. A flail chest occurs when two or more ribs are fractured
in two sites. The block behaves in a manner illustrated in figure 4.
IN FLAIL CHEST:
- WHEN AIR MOVES IN FRAGMENT SHIFTS IN (negative intra-thoracic pressure)
- WHEN AIR MOVES OUT FRAGMENT SHIFTS OUT (positive intra-thoracic pressure)
Fig 5
Above: multiple fractured ribs and subcutaneous emphysema on the right hemithorax
(Fig 5). Note the ribs on the right side are converging on each other and there is a
difference in the intercostal space between right and left side.
42
Fig 6
Fig 7
In fig 6 we see a partial pneumothorax on the right side, a massive subcutaneous
emphysema on the right side, a partial collapse of the lung with obliteration of the right
costophrenic angle. Subcutaneous emphysema and a detailed view in Fig 7 of the major
bundles of trapezius.
Tension pneumothorax
Fig 8 Tension pneumothorax
43
Hyper inflated lungs
44
Haemo-pneumo-thorax from stab wound
8 Radiology – Dynamic or Paralytic Ileus?
Fig 1
Fig 2
In Figures 1 and 2 take note of the air fluid levels on this erect plain abdominal X-ray. As
you can see from the illustrations below there are few causes. If you identify a loop (and
in Fig 1 there is only one definite loop) you can decide if the air fluid level is on the same
plane or not. If they are not on the same plane it means there is a force pushing the
proximal level up and this means we are dealing with a dynamic ileus. The force is
peristalsis trying to push the liquid beyond the obstruction.
45
It is generally difficult to find an isolated loop. But then we have other signs. If the
abdomen is full of gas, like in Fig 3, you know you are dealing with a mechanical
occlusion because from one point onwards there is no more gas. The rectal ampulla is
empty and you know you are dealing with a mechanical problem.
Fig 3 mechanical obstruction = no air in rectum
The following two Figures 4 and 5 show the evolution of a case of “rolhao de ascaris”.
Figure 4 shows the pre-operative situation. The surgeon decided to operate and to remove
some of the ascaris from the intestine through a small incision. Fig 5 shows the same
patient two days later, clinically occluded. Probably most of ascaris left behind were
going through the ileo-cecal valve and created a temporary occlusion which resolved
spontaneously the following day with the elimination of the residual amount of worms.
46
Fig 4
Patients who cannot stand can be examined with a lateral view while on dorsal decubitus.
This is very convenient for children and for patients who cannot adopt a standing
position.
The lateral view obviously shows air-fluid levels in the abdomen and assists in the
diagnosis of bowel occlusion
47
9 Radiology – UGI
The upper oesophagus is a distensible tube that, after a bolus passes, collapses in a multifold way like in picture above. In radiological terms this means that after barium swallow
the distension reduces and we only see the barium in the mucosal folds as in the picture X
and Y. What we then see on the X-ray are faint parallel lines. If these lines are there, you
can be sure the oesophagus is normal.
Fig 1
As you know from experience, liquid travels very quickly through the oesophagus,
something we all feel when drinking a very cold liquid. You suddenly feel the cool pang
in your stomach. So liquid barium should travel very quickly down the oesophagus. If
not, there is some abnormality that needs to be investigated by referring the patient on for
further tests.
48
Fig 2 (a, b)
As you can see in the above image, the oesophagus, after the passage of the barium
bolus, reverts to its normal size and is seen as several very thin parallel lines (arrows).
Fig 3
Fig 6
49
Fig 4
Fig 7
Fig 5
Fig 8
Relationship of trachea and oesophagus on lateral X-ray and on an anatomo-pathological
slide
Fig 9 (a, b)
Fig 10
A barium swallow fills the folds of the non-distended oesophagus (Fig 10) and is seen on
the X-ray as thin white parallel lines. As can be seen from the above image, barium ends
up in mucosal folds and therefore is seen on X-ray as thin white lines. Any change to this
pattern indicates pathology.
50
Carcinoma of the oesophagus is very common in Mozambique and should be diagnosed
early. Difficulties in swallowing should be investigated with a thin barium swallow to
exclude carcinoma of the oesophagus. The thin barium swallow is also used as a
diagnostic tool in cases of oesophageal stenosis after caustic ingestion. In this case, if the
oesophagus is normal, remember to check the stomach. Caustic fluids ingested for
suicidal purposes can sometimes not damage the oesophagus but produce a pre-pyloric
stenosis.
(See in UGI case n 25)
Fig 3, 4, 5 still reflect the normal passage of contrast medium through the oesophagus,
while in Fig 6 you see a sudden stop of flow of contrast medium and there are space
occupying lesions because you see faint amounts of contrast medium. Suddenly then the
tumour ends and normal oesophagus patterns continue into the gastro-oesophageal
junction.
In Fig 7 and 8 you should observer the dilatation of the proximal oesophagus, the sudden
stricture, the irregular pattern of the oesophagus occupied by a tumour.
51
Fig 9 (a, b, c)
Fig 10
Figure 9 shows the relative position of the anterior tracheal wall and oesophagus which is
best seen on lateral X-rays b and c. Fig 10 shows then the worst unfortunate case (which
should not repeated in your hands) of a barium swallow given to a patient with a fistula
between the oesophagus and the trachea. As you can see on the left side we have filling
of the distal alveoli and the clear position of the lung compared to the diaphragm. A
trickle of barium does reach the stomach and you can see the dense and heavy barium
make its way along the smaller curvature of the stomach.
Fig 11 (a, b, c, d) UGI with gastrografin
This time we used the image intensifier. The image intensifier allows one to see images
in real time on a screen and you are able to take x-rays as well. So you see the contrast
medium in the upper oesophagus (a), then a dilatation (b) and a trickle of barium going
out of it (c) and moving freely into the stomach (d). This series shows a stenotic area in
the lower oesopahgus and you can notice that on fig b, c and d the shape of the
oesophagus below the dilatation does not change, a sign that the mucosa or the whole
oesophageal wall is infiltrated by inflammatory or malignant tissue.
After the ingestion of contrast media, x-rays were taken at 4 minute intervals. Contrast
medium passed easily into stomach and showed filling of the stomach but a halt at the
pylorus.
52
Fig 12
In the following X-ray there is passage through pylorus and a gas shadow (which should
be colonic gas) is present above the small curvature. We would have expected a quick
passage through pylorus and duodenum of contrast medium which did not happen
Fig 13
After half an hour we took the last X-ray showing a large amount of gastrografin still
present in stomach and practically nothing in the small bowel.
53
Fig 14
The data presented may be normal:
-gastric emptying may be complete in about two hours
-in case of duodenal occlusion, I’d expect an abnormal gastric distension and vomiting
-the passage of contrast medium through the pylorus may be slow.
Finally I’d remember that after two hours the stomach is almost completely empty and
the contrast medium reaches the distal ileal loops and then after six hours the small bowel
is almost completely empty and contrast medium reaches the colon.
Achalasia and corkscrew oesophagus
Fig 15 (a, b, c)
54
Fig 16
Para-oesophageal hernia
Fig 17
Fig 18
The stomach
Peptic ulcers are not very common in Mozambique. Their pathology is mostly caused by
the perforation of ulcers caused by AINES. The second most common pathology is
caused by damage resulting from the ingestion of battery fluid for suicidal purpose. The
sulphuric acid causes either a stenosis of the oesophagus or a pre-pyloric stenosis.
Normally the diagnosis is quite simple as the patient admits to battery fluid ingestion.
Infection with Campylobacter cannot be diagnosed and is generally only established if
there is no history of AINES ingestion.
There is a widespread belief that battery acid ingestion causes only oesophageal stenosis.
Please ensure to always check the stomach if the barium easily passes through the
oesophagus in a patient with a history of acid ingestion and weight loss.
In the following X-rays you will see what happens if the stomach is stenosed before the
pylorus.
Fig 19
55
Fig 20
Barium normally travels quickly through stomach and between one x-ray taken and the
next one (more than 5 minutes later with present techniques) there should be already
barium in the small bowel. If this does not happen then there is a delay in the stomach
emptying. The cause is generally due to pyloric stenosis. In the above case the difficulty
in leaving the stomach has caused a dilation of the stomach which may even be visible in
the pelvis.
Fig 21 (a, b, c)
The same situation is in the above case. The stomach is progressively filling and there is
still no movement through pylorus. The foam on the right image (c) is saliva which is
continuously swallowed and fermentation of swallowed food. There is no movement of
contrast medium into the small bowel and therefore the diagnosis is that of gastric outlet
obstruction. One frequent cause of gastric outlet obstruction is battery fluid ingestion. If
battery fluid does not burn the oesophagus it can burn the pre pyloric area and cause a
very tight stenosis. Remember to check the stomach in every patient with a history of
battery fluid ingestion.
Fig 22
Fig 23
As you can see from the above two pictures the stomach quickly empties its contents into
the duodenum and further with powerful peristaltic movements. In a normal patient this
56
happens rather quickly and if, after taking one picture, you see on the next one the same
appearance, then you know there are problems.
Fig 18 shows a lateral image and you can see the peristaltic waves propelling barium
through the duodenum and small bowel. Fig 19 is an AP view and shows the same
process and the movement of contrast medium into the small bowel.
Fig 24 shows the duodenal C-shape which is usually not wider than 2 vertebral bodies. If
it is, there might be enlargement of the head of the pancreas.
Fig 25
Fig 26
In this X-ray you can observe the air in the stomach and the faint lines of the plicae
mucosa of the stomach because there is a large abdominal mass displacing bowel below
towards the pelvis and the only air to be seen from L1 to L4 is that in the stomach. In Fig
22 you see an oblique view of a barium filled stomach.
57
Fig 27 (a, b, c)
Note that on the above images (Fig 23, a, b, c) the medial portion of the stomach’s small
curvature is similar and does not contribute to the peristaltic movement running across
the stomach. This is an indication of the inflammation of the stomach wall (water in
tissue) or a tumour occupation of the same area (malignant cells in tissue). Another sign
is the time elapsed from the barium swallow and the barium reaching colon. The
stomach has only partially emptied, but you can still see the original shape. It means there
has been a delayed emptying and it indicates pathology.
Fig 28 (a, b)
Note that inflammatory tissue (tissue around a peptic ulcer), scar tissue and cancer tissue
do not contribute to the peristaltic waves going through the stomach. So if you see the
same aspect on two different images of one portion of the stomach you can definitely tell
that there is a tissue swelling, or a fibrotic change or a tumour invasion. Unfortunately we
do not have two consecutive images of this UGI series, but the relationship of the ulcer
bed will be the same on several consecutive images. But we have the next two ones....
58
Fig 29
Fig 30
In Fig 25 and 26 we have two consecutive images of the same barium swallow. The
oesophagus appears dilated before the oesophageal gastric junction and full of contrast in
both x-rays. The oesophageal-gastric junction is stenosed in both images and the
distortion of the major curve is similar in the two images. It did not change over time and
this indicates that the gastric wall does not contribute to the peristaltic movement and
therefore is either inflamed or invaded by a tumour or it is contracted due to scar tissue.
The rest of the duodenum and diginum appears normal. Note how much contrast medium
has entered the small bowel from fig 25 to figure 26.
TRAUMA
Fig 31
Fig 32
In Fig 27 and 28 we have a post-traumatic diaphragmatic hernia. Part of the stomach and
some intestinal loops have passed through the diaphragm. You can see the normal
position of the right diaphragm (arrow).
59
In the next image, Fig 29 plain film shows a stomach filled with semifluid stuff. In fig 30
barium enters the stomach and due to its gravity flows over the stomach content. In fig 31
some barium collects in the fundus of the stomach. From these three images we know the
stomach is dilated, it extends from T9 to L3.
Fig 33
Fig 34
Fig 35
In these X-rays we see the gastric bulla below the diaphragm, the column, the ribs and
inside the stomach a foamy appearance. This is long-standing gastric content, mixed with
air in saliva and fermentation of ingested food. It indicated that the stomach is not
emptying properly. Once you note this foam you have to look for the cause and you will
see what happens in the next slides. The barium moves along the lesser curvature and
then falls to the bottom, slowly mixing with the stomach content.
Fig 36
60
Fig 37
In Fig 32 and 33 we observe, after a 10 minute lapse, a stomach not emptying itself and
we can easily diagnose a gastric outlet obstruction
Fig 38
Fig 39
The same is indicated in figure 34 and 35 where we have a supposed annular pancreas
delaying the passage of food into duodenum and an outlet obstruction of the stomach at
its pylorus.
Fig 40(a, b, c)
Here is a similar collection of images through the use of an image intensifier. Here we
can follow, in real time, the progression of the contrast medium during the examination
and we can clearly see that the stomach is doing its best to push the contrast medium
forward, but nothing happens. So we diagnose a gastric outlet obstruction and refer the
case to the surgeon.
COMPLICATION OF PEPTIC ULCER
1) STENOSIS (X-ray + barium) Fig 36, 37
2) BLEEDING (clinical diagnosis)
3) PERFORATION (plain abdominal erect film – free air under diaphragm) Fig 41
61
4) MALIGNANT CHANGES (X-ray + barium) Fig 27 a, b, c
PNEUMOPERITONEUM
This is a common occurrence in Mozambique. Main causes: perforated peptic ulcer
(AINES and/or Campylobacter pylori) or perforated small bowel due to the perforation of
typhoid plaque.
Fig 41
Fig 42
Fig 43
Typhoid fever is common and patients present with an acute abdomen, air under the
diaphragm and at surgery you will observe a perforated small bowel loop.
OESOPHAGEAL VARICES
Oesophageal varices are very common in Mozambique due to portal hypertension caused
by schistosomiasis and are caused by alternative paths the veins find to bypass high
pressure within the liver. Oesophageal varices rupture very easily and the bleeding can be
massive. One spoon of barium in some water is enough to display the varices and to
assist in the decision to refer the patient.
62
Fig 44
63
Fig 45
64
10 Radiology - Urology
Above: a section of a ureter. Note that the ureter has a muscular wall and this explains the
pain experienced during renal colic. The path of the ureter is roughly over the vertebral
transverse processes and then curves out in the pelvis to end in the bladder trigone. This
is where you are going to look for possible ureteral stones if a patient presents with renal
colic.
The ureteral path: note that it is easy to identify the ureters on an IVP (intravenous
pyelogram) (Fig 1) and where the ureters enter the bladder (Fig 2)
Fig 1
65
Fig 2
The urography on Fig 1 and Fig 2 indicate the normal position of the ureters. In Fig 3 you
can try to find a stone on a normal X-ray. If the patient is not full of air and has been
prepared with a laxative or an enema and if he is NPO for 12 hours.
Fig 3
This is a normal KUB (kidney ureter and bladder area) without contrast.
Fig 4
66
Fig 5
In Fig 4 and 5 the bladder is full of urine and contrast medium and the left kidney is
dilated and poorly functioning. Both x-rays are taken 30 and 50 minutes after an IV
contrast injection and there is a very faint concentration of urine in the right kidney which
is dilated. The big whitish shape is likely to be a well delineated tumour.
Anti reflux mechanism: oblique path of ureter, with distension of bladder, lateral pressure
obliterates the ureter and reflux is impossible.
67
NOTE THAT URETERS RUN APROXIMATELY ON THE TRANSVERSE
PROCESSES OF LUMBAR VERTEBRAE. IF YOU WANT TO FIND A SUSPECTED
URETERAL STONE THERE IS WHERE YOU HAVE TO LOOK FOR IT.
68
HYDRONEPHROSIS
As you can see from the next two IVPs there is bilateral hydronephrosis on the right (Fig
6) and on the left image there is only one hydronephrotic kidney (Fig 7). The difference
in concentration of the contrast medium between the two kidneys gives you an indication
of the reduced function of the pathological kidney.
Fig 6
Fig 7
Remember to look for calcification of the bladder, a sign of Schistosomiasis. It is quite
common and carcinomas induced by Schistosoma eggs is not rare. Sometimes you can
even see the faint evidence of calcified ureters like in fig 9.
Fig 8
Fig 9
It is not uncommon in a Schistosoma infection to see a tumour stimulated by egg
deposition or egg degeneration products.
69
Fig 10
Fig 11
Urography Fig 10
Uretero-hydronephrosis appears on the left side. Right ureter and kidney shape is normal.
The bladder is distended, with multiple filling defects on left side and loss of border
definition ipsilateral; this data is due to an endoluminal lesion occupying space. During
surgery a big bladder filling tumor, stage 3 according to the annexed classification. In fig
11 the image of the tumor containing Schistosoma eggs.
In fig 12 a patient presents with an inguinal hernia and with something unusual in the
hernia sac: a bladder diverticulum. With prostatic hypertrophy, continuous straining can
produce a direct inguinal hernia with the bladder wall in the hernia sac. Since urine stays
for long time in a diverticulum, urinary tract infection is common in these cases. So
remember Urinary tract infection + direct inguinal hernia = possible bladder content in
direct inguinal hernia sac.
70
Fig 12
Ascending Urography.
Bilateral uretero-hydronephrosis, several bladder diverticula, small inelastic bladder with
inflated Foley catheter balloon. This being an ascending urogram (i.e. contrast medium
via a foley catheter) we can see dilated ureters up to both pelvis and bladder diverticula
and the concentration of contrast medium does not give information on kidney function.
In this case the uretero-cystic junction is incompetent.
Fig 13
71
To-day urinary pathology is more easily identified using US. In the first 3 images below
you can observe a bladder tumour, a tumour adjacent to the bladder and a nephrotic
kidney.
Fig 14
In the last image, we have included an US of a small ureterocele (arrow). This is quite
rare but you need to be able to identify it. Urologists will usually operate in this scenario.
Sometimes you request an X-ray to eliminate something and then you pick up something
completely different as in the last image. If you do not see it, try on the last page. But one
of my professors told me that you do not need to know everything, you just need to be
careful and look at each section of the image and then, sooner or later, you will observe
what is abnormal.
FIG 15
72
Trauma
The following images show a very unusual display of pelvic disease. But this being
Mozambique, some patients even get injured by elephants as the patient in Fig 16 while
in Fig 17 a young man had a serious motor-bike accident.
Fig 16
73
Fig 17
11 Radiology – Paediatric
Fig 1
Fig 2
Fig 3
AP abdomen of 10 day old infant brought from home presenting with a distended
abdomen.
Chest: reduced chest space due to pneumo-peritoneum and distended abdomen.
Right and left chest appear normal though compressed by high pressure air in abdominal
cavity.
Abdominal cavity: air below diaphragm. In upright position no air-fluid levels visible in
bowel loops. Lateral view shows outline of diaphragm between abdominal and chest air.
In lateral view small bowel loops with air-fluid levels at different heights is a sign of
active peristalsis (nevertheless, also an adynamic ileus may show a similar
appearance).
Ok
Fig 4
74
Fig 5
X-ray of a 3 month old baby with normal lung and heart, distended oesophagus after
small contrast meal. Dilatation of oesophagus terminates at gastro-oesophageal junction.
Contrast medium present in stomach with no sign of progressive movement out of
stomach. Distended small and large bowel loops.
The second X-ray was taken approximately 10 minutes after the first one. This is the time
generally needed to go and develop the X-ray and to ensure that the image is of an
acceptable quality. In the second X-ray, the oesophagus went back to a more regular size,
but the contrast would not progress from the stomach. Nevertheless air reaches small
bowel.
Ok
Ano-rectal pathology in newborns. The following images show barium enemas of
Hirshsprung’s disease patients at different stages.
Fig 6
75
Fig 7
Fig 8
Fig 9
Fig 10 shows an imperforated anus and a recto-vesical fistula. The patient is passing
dark corpuscolated foul smelling urine. What would be your next question?
What about renal function?
76
Fig 11
The answer to the above question is this image.
The patient has bilateral hydro-nephrosis (only one kidney shown)
77
78
12 Surgical Emergencies in the Newborn
Dr Alessandra Cattani
Neonatal bowel obstruction
Intestinal obstruction is the most common abdominal emergency in the neonatal period. It
is almost always the result of a congenital anomaly of the gastrointestinal tract.
Mortality in surgically untreated patients is close to 100% and the rate of survival is
closely related to the time of surgical intervention.
Etiology
Multiple possible etiologies:
- duodenal atresia/ stenosis/ web – annular pancreas
- malrotation
- jejunoileal atresia
- meconium ileus
- Hirschsprung’s disease (mega colon)
- MAR (anorectal malformations)
- NEC (necrotizing enterocolites)
Clinical signs
The 3 typical signs of intestinal obstruction:
1) Abdominal distension
2) Bilious emesis
3) Delayed meconium passage
Indirect sign:
Maternal polyhidramnios => the foetus is unable to swallow the amniotic fluid
Associated anomalies
• Meconium ileus => cystic fibrosis (20% of patients with cystic fibrosis presents
meconium ileus)
• Duodenal atresia / malrotation => 50% presents cardiac, anorectal or genitourinary
malformations; 40% presents Trisomy 21
• NEC => prematurity
Physical exam
- Evidence of dehydration (sunken fontanelle, no skin turgor)
- Abdominal distension or scaphoid abdomen (respectively in distal or proximal
obstruction)
- Any congenital anomalies (perforate anus?)
79
Diagnostic tests
Plain abdominal radiography: look for pattern of the gas
The presence of air-fluid levels is the typical feature suggestive of an intestinal
obstruction.
Others radiological features suggestive of the etiology are:
- “double bubble” sign => duodenal atresia or malrotation with volvulus (air in the
stomach and proximal duodenum)
80
dilated small bowel loops => jejunoileal atresia
- “soap bubble” appearance of portion of the abdomen (Neuhauser’s sign) particularly the
right lower quadrant => meconium ileus
(The presence of calcifications in a meconium ileus is a sign of a perforation with
meconium peritonitis)
81
- Fixed loop in the upper right quadrant, pneumatoses intestinalis, subdiaphragmatic air
=> NEC
82
- megacolon => Hirschsprung’s desease
Upper way contrastrography: if you suspect proximal obstruction or malrotation
83
Enema opaco: if you suspect distal obstruction
Treatment
Duodenal occlusion => always requires surgical treatment (duodenoduodenostomy or
duodenotomy with the excision of the web)
Malrotation => surgical treatment
NEC with perforation => surgical treatment or abdominal tube
Meconium ileus without complications and functional occlusion of the colon (meconial
plug) => contrast enema
MAR: in neonates with anorectal malformation, the clinical presentation and location of
the rectal cul-de-sac determines the type of management => one-time repair in a low
lesion and primary colostomy and delayed surgical repair for a high or intermediate
lesion.
Oesophageal atresia
Oesophageal atresia is an abnormality in which the middle portion of the oesophagus is
absent. The oesophagus may end blindly into a pouch or may connect to the trachea.
Classification
5 types of oesophageal atresia:
84
Type 1: oesophageal atresia without tracheo-oesophageal fistula
Type 2: oesophageal atresia with proximal tracheo-oesophageal fistula
Type 3: oesophageal atresia with distal tracheo-oesophageal fistula
Type 4: oesophageal atresia with proximal and distal tracheo-oesophageal fistula
Type 5: tracheo-oesophageal fistula without oesophageal atresia (H-type fistula)
The most common is type 3.
Type 1 and 2 present a long gap between the two ends of the oesophagus; type 3 and 4
present a short gap.
Associated anomalies
VACTERL syndrome
(V = vertebral; A = anorectal; C = cardiac; TE = tracheoesophageal; R = renal; L = limbs)
Clinical signs
- Excessive drooling after birth
- Choke and cough with feeding
- Cyanosis with feeding
- Pneumonia for aspiration of saliva
- Gastric distension (stomach) during crying and chocking if distal fistula is present
Indirect sign:
Maternal polyhydramnios => the foetus is unable to swallow the amniotic fluid
Diagnostic tests
Attempt to pass a nasogastric tube
Plain abdominal radiography:
Shows the tube in the upper pouch
Type 1-2 => absence of air in the abdomen (GI tract)
Type 3-4 => presence of air in the abdomen (GI tract)
85
Contrast in the upper pouch:
Diagnostic for oesophageal atresia and for presence of a proximal trachea-oesophageal
fistula.
86
Treatment
Depending by the distance between the two ends of the oesophagus:
Type 3-4 (short gap) => primary repair: closure of the fistula and oesophageal repair.
Type 1-2 (long gap) => cervical (proximal) oesophagostomy for drainage of saliva
Feeding gastrostomy
Closure of the trachea-oesophageal fistula
The repair of the oesophagus is delayed
Congenital diaphragmatic hernia
The congenital diaphragmatic hernia results by failure of the posterolateral part of the
diaphragm to close. Once the diaphragm has failed to close, the abdominal contents
herniate in the chest: the stomach, the spleen, part of the liver and most of the intestines.
The lungs are both small and immature: this probably results from compression of the
lungs by the abdominal organs herniated in the chest.
80% of congenital diaphragmatic hernias occur on the left side.
Bilateral forms are rare.
Clinical signs
- Neonatal cyanosis
- Difficulty with breathing at birth
- Flat abdomen because of the lack of abdominal contents
Diagnostic tests
Chest x-ray:
- Presence of the intestines and possibly the stomach in the chest
- Heart’s shift to the right side
87
88
89
Upper way contrastrography: only if necessary in order to identify the presence of the
intestines in the chest to discern a diaphragmatic hernia from cyst-type abnormalities of
the lung
Treatment
Depending on the function of the lungs:
• If it is fairly good => surgical treatment: replacement of abdominal contents into the
abdomen and closure of the diaphragm
• If it isn’t good => ECMO (Extra Corporeal Membrane Oxygenation).
90