Abdominal X-Rays Made Easy 1st ed

Abdominal X-Rays

Made Easy James D. Begg

ae es FIlCll

Cc:nult.lntR.td ~, ~.. \ic1vN ~t.ll.

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IIId Homr.ary Smior Lrctun'r in ~R.tdIl1logy.

l ni''f'r,jty Pl DJnd.." ,

Xu&rdt:K

A •

CHURCHill LIVINGSTONE En\BL'RCH I1X\TX JN MW,\,()l/.K J1 111.AIJHJ'-1IA snres 5YlY.\TI TORONlU I'HI

Contents

1. How 10look at an abdominal X-ray 2. Solid

orga ~

3;

3. Hollow organs 55

t Abnormal gas 86 5. Ascnes lI b II. Abnnnnal intra-abdo minal calcification

\HI

7. The fl;'mall' abdomen 154 8. Abl:h'minal lta uma

157

9. Ialmgt'nic objects 1M

10, Fi.lf\'ign bodjes, artl'fdcts. 11. The «ull' abdomm 12. Hinh

Indn

183

17\1

In

JJrisk>dJin~ illldg~

170

C a fer 1

How to look at an abdominal X-ray Ap roach to the film •

•

•

The init ial inspec tio n of an y X-ray be gin s w ith a technical assess ment. Establishment (If the name, . .1.111;', date of birth, agl.' and sexof the pollit'nt at the (lUtset is crucia l. There art' no prizes for making a brillia nt d iilgnos is in the wrong patien t' Further information relati ng to the wa rd number OT hospi tal of origin may give an idea as to the potent ialna tu re of the patient' s problem, e,g. gastroin tes tina l Of urinary, .111 (I( which information ma y be visible on the name badge, so never falltolock at it critically. Th is can be wry helpful inexams. You will notice, however. that the dalilon the patients' name badges

in this book haw had 10 be Il.'ffiUVOO to preserve their anonymity. Establish the projection of 1111' film, Virtually t'wry abdominal X-ray is an AP film, l.e. the beam p,l SSl'S from fro nt to back w ith the film behind the patient, who is lying dow n wit h the X-ray m achin e overhea d . but these are freq uently accompa nied by e rect or eve n dec ubi tus views (a lso APsl , Usually the radiographer will ma rk the film wit h a badge or wri te on it by h and 'Su pine or 'EI'l'Ct' to guide you, so seek this out and use it, Later on you must learn to work out for yourself how a given film wa s taken, from the relative pos ition s of organs, fluid, gas etc.

NOthe standard 35• .0 em cassett e used to X-ray an ad ult is tan talisingly smaller than theaVl'I'agl' normal human abdomen , and usu ally Iwo films all;' required to get the entire anatomy included from the dia ph ragm to the groin s, Make sure this has been don e before accept ing an y films for d iagnosis, If you don' t, you will miss something impor tant and you wo n't know you've done it! In obese patients casset tes may have to be used transversely, i.e. in 'landscape' as opposed to 'portrait' mode. Rotation is nol usua lly a probl em as most patients art' happy to lie on their backs. Underpe netration is not usually such a pr oblem as in the chest. If yo u can see the bones in the spine, then mos t of ever vthmg else you need 10 see will

Approach to the fil m continued probably be vislble as well. However; any overexposed (i.e. excessively dark)areas on an X-ray must be inspected. again with a bright light behind them (built into many viewing boxes for this purpose, or available as a separate device), as failure to do so may cause you to miss something very importa nt, such as fret' air under the diaphragm, representing a potentia lly fatal condi tion. It is worth knowing that only five basic densities a re normally present on x-reys, which 'lppear thus: Gas

Fot Soft tissue/fluid Bone/ calcification Metal

black dark grey light grey white intense while

so you can tell from its densi ty wha t something is made of. There is, however, a summa tion effect with large organs such as the liver which, because of their bulk, can approach a bony densit y. In the abdomen the primary structures outlined art' the solid organs, such as the liver, kidneys and spleen; the hollow organs (i.e. the gastrointestinal tract); and the bones. These structures can be classified as: L 2. 3. 4. 5. •

•

•

2

Visible or not visible, and there fore whether presen t or potentially absent; Too large or too small; Distorted or d isplaced; Abnormally calcified: Containing abnormal gas, fluid or discrete calculi. Take a systematic approach and work your way logically through each group of structures as a checklist. Initial inspection may reveal one or two major and obvious abnormalities, but you must still drill yours elf to look through the rest of the film - and you will frequently be sur prised. by what you find. Think logically.You should be able to Integrate your knowled ge of anatomy, radiogra phic densi ty and pathology with the findings on the X-ray,a nd work out what things are and what is going on. Look upon x-rays as an extension of physical examination, and rega rd radiological signs as the equiva lent of physical signs in clinical medicine.

The abd ominal X-ray: sca nning the fil m The supine AP film This is the film most frequentl y taken and shows mos t of the stru ctu res to the best advantage. The optimum information can only be obtained from it by using the correct view ing cond itions. An X-ray shou ld only ever be seriously inspected by uniform tran smitted light coming th rough it, i.e. a viewing box . There is no place for wa ving it about in the wind as irregula r illum inat ion a nd reflections will prevent 10-20% of the use ful information on it being visualized. Look for (Fig. 1.1):

• • • • • • • • • •

•

,

The bon es of the spine, pelvis, chest cagr.- (ribs) and the sacro-iliac joints The d ark margins ou tlining the liver, spleen. kidneys, bladder and PSOilS muscle s - th is is intra -abdominal f,1I Gas in the body of the stomach Gas in the d escend ing colon The wide pe lvis, ind icating that the pa tient is fema le Pelvic p hlebolith s - norm al finding Minor joint space narrowing in the hips (norm al for this agel The granu lar texture of the amorphous fluid faecal matter containing pockets of gas in the caecum, over lying the right iliac bone The 'R' marked low down on the right side. The marker can be anywhere on the film and you often have to search for it. All references to 'right' and 'left' refer to the 1\!/ifIlI'S righ t and left. Note the name badg e at the bottom, not the top. Check that the 'R' mark er is com patible with the visible anatomy, eg - liver on the righ t - left kidney higher than the right - stomach on the left - spleen on the left - heart on the left, when visible. The dark skinfold going right across the upper abdomen (nor mal).

The abd ominal X..,.ay: scanning the film Hepatic liver

Bexure

Skin fold

conl'nved

[, ; kidney

Splenic Ilell.ure

Gos in -descending oo' margin

--~"l!!!:i:!- Sccro-ilcc joints

1I::=:i!~- ,,=* Bladder _ Phlebolith

, Fluid faeces and gas in caecum

Fig. 1.1 - Adult supine AP radiograph in a 55·year· oldwoman.

5

The abdom inal X-ray: scanning the film conlinved

Rugal folds and gas in sto mach

Shadow of peni s (indicating male childl and cndroid pelvis

llne of unfused fe moral epiphysis

Fig. 1.2 - SupineAPradiograph of a child with leN·sided abdominal poin.

6

The abdominal X-ray : scc nnin g the UklkJt( Fi~.

• •

hlm

conltn....,a

1,2):

The 'rijo;ht' m arker at thetop left-haod corner of the film The heart ~h.1JIIW tin tfu- !\dID!' ~iJI' abo ve the right hemi dla ph ragm tdcvrrocard ia)

• • •

Theoutline \If the stomach f;ols and ruga l lolds 1m Ilk' right TbeIin-TI'" the Loft Unlu~ tl'lphy....... in tht' femora . This is d child \\'hr"'t' gro..... th is mcomp lcte , his small ..i / l' 1,·.IJinjo; to tht' inclusion tlf 1,"-, Ill.... W r hest and UPf'l'f th i ~hs o!s well a~ all oi tho.- d~"n"..n - norrt'"ot'ntinio\a f"lrti.tl ·b.tbn~ra m' ",. il i" kno..... n

in raJK1K'KY'

\8 This \\;a.. rh't a T.lJi',;r,lrhic error ~l d ~t'n uint' "ilu.. inversus with 1.1t..;;'f..J ~lCitl._

As....ilh Itk- c~l or a limb, t-.t.lbli'ohmt'llt at left and right is t"""ol'!\haL You do noc want ttl remove a fKll1J\dl "kim'y from rbe right side when it is the l~'(ln tht'

Irtl tlw t b.JI"lW....-d, MdU....•til a fdUlly X-ray (and thi!'o ha.. moo dollt.'!). Both in and in clinical practin' ~ilu" inver..us, or mirror Iran!'oP'o",ilion of the ibdomin.al contents. may tlfl1r be diJ~Tl(""",l'ol e m>m 1M apparmt iocompatitoihly oflhr L/R mar\.t1' and lht-' ; ..rble,u\,llt.my wben it has been owrb>lt'IJ chnKally. Tbe L/R mJrh,. I1\dY of (IlUN' be looJl1\'ctlyplaced ibdf as a result I,f radioj!;faphk error, and thi..haPP'o'Th \~rith di...u rt>in~ fm.IlWnt:'Y (t"Speridlly with limp.. in aswll~'l _ You mU'>lIht.'Tl ~(l bad. and clk'Ck \\ith tnto radiographt.-r fiN MtlT\' ml!odiagnt.... m~ -uu.. mversu-, tll" unmu......,lrily n-qUt...ting a further X- ray• .\!'o.\ taull\· film ran 1-1' (w n,·lt, l wtth a pen. If in JuuM . n-evarnirwlbe p.ltit'TIt. f"Um~

\I oroll: Alwol y' ( heck Irfl and right on r ,"rl)" film. ~urgiu l o~u l ion ...

(onbscuring genuine bomlesion... and !':1'Ot'Tatinf; fa l~' on e, (especially O\"l;'T the sacrum). The di~o\"l'TY of Pagt'l'S Ji"l'd'.I.', myeloma or meta ...tatic di;,('il~', however; willotten TTIiIh' YOUT search worthwhile. Lt_,k at Wig. 1.3): •

The bones: the inilidl routine in..penon of the hone; showed an incidental finJin g ( If l.'\ tt'TI-.iw ~11.'Tl.l';i ... in the right side oi the pelvis compared with the other norma l sidt', and some slight bony expanston.

This is Pagt'!:' s disease, a pl'\'TTlilliglldnl condition in 1% of patients. ~f or;l l :

8

Alw;lys chec k th e bon es .

The abdominal X-ray: sca nning the fi lm c:oMn.-J

Fig. 1.3 - Unilolerol5C/erosis - right ltemjpelvis This is a 62·year-old mole potient X-rayed for unexplained abodominal pain. No radiological coose was Found onthe plain film ~ but endo~copy showed a duodenal ulcer.

9

The abd ominal X-ray: sca nning the film con lin.....d

Fig, 1.4 This is a 2().minvle IVU Film from a 68-year-old man with a craggy moss palpable anteriorly on PRand haematvrja.

10

The abdominal X-roy: sccnmng the film «Jfl~"..,.d 1.IIIIk dl (Fi);. IA ):

•

The bonec tht.· f\' ,In' multiph- dense flri in the f'l'lvi!> a nd vertebrae of Iht'

lumb.u ~f'tnl·. ~'dft>

typil'dl "dl'rllti~' lTk1d... t.I"l~ frum d carcinoma of the prostate.

\toral: Always chec k the bon e...

lotll and has m.m~' GIU.,..."

led:. for the

b~o(Jder IFis,

1. II

\\lthin thl' pelvi.. .I I,Hgt' mass (If ....Iit-tb..ue dl'll ..ily ( fad i~a rh ica ll y water Jt'lbii)o' '" .... >tt·h ....ue dl'll-..lh' . mJy be rn....'tlI.lS a ~ult IIIa full bldddt'f outlint.>d

by pt'ri\ 'e-ical jolt, dod in

jl'ffidll~,

evee nunnally, volume. up to two tnres may

cccur. pushing 0111 tilt.' gut up oIM 'JUt of till' tru e pelvi... If there is d'lObi as 10 the natun" of ..uch a ma....a p'''I ,micturilillO film may ht· taken Of an ultra amd -can

J,:w. Bt-ing fullt" fluid, tlw tolokidt'1" behave.... r.wioJl:fdphKdlly Iik a llid ~n.

led:. for the

ute rus

Thb fadit~faphicall~' .... llid vructure ..ib 110 hiP of and ma~' indent tho: tolokidt.... II lNyoa:a..itlnall~' be ....'t'n ..pt.lnldnt'tlUsl~' dod i.. often well demon..trated indil\'ctl~' al an IVU t'\Jmin,ltiun, (,lll"lng ,1 di ..unrt concavity on the uppt.'r t>dge of Ihl' bladdt'J, In m,m~' patient.., hllwt'wr, il cannot be id..nnned on pla in film...

13

The hollowviseere (gas-containing gastrointestinal troctl

On a normal film, any structure outlined by g,lSin the abdomen willbe part of the ~astmintt'stin,ll tract. Remember: on a supine AI' radiograph the pauent is lying on his back, so under gravity ilny fluid will lie posteriorly within the gut and the g,b in the bowel will float anteriorly on top of it. NB fluid level s do nol appea r on su pine AP fil ms,

Failure to appreciate this mdY lead to ~mss misunderstanding and l'Hors in diagnosis. To demonstrate fluid levels you need an /'reel film or a dl'ClJhilw; film taken with a horizontal beam, Think systematkally and work your way down through the gastrointestinal tract. identifying structures (rom the stomach to the

rectum. look for the stomac h ln the supine position, depending ()11 how much is present, the g,lS in the stomach will rise anteriorly 10 outline variable volumes of the body and antrum of this structure. to the left of and across the spine around the lowermost thoracic or upper lumbar levels. Simultaneously the resting gtric juiC'l' Jr".'" on the plain film The largoamount of ~,l;. present, again in thl' body of the stomach. The patient has in fact been given effl'r\'l~t'nt powder to generate excv-s carbon dioxide to distend tht' stomach and generate 'd ouble contrast', i.e. an outline (If the mucosa with barium and 1\.ls. How the fundus is seen only in 'single wntr.lst' on thiv view, i.e. barium alone.

look for the small bowel Because of f'l'fistal~i-s the outlinl' of the gils in thl' normal small bowel ts often broken up into m,my small plll.'kl·ts which form plilygon,ll shapes, but oCCUpy.l gt'llt'ralJy central location in the abdomen. when more distended, the cbaractertsnc'valvulaeconmventes', \,rroilloJ spring-shaped folds ,CT(l!'sing theenttre lumen

1Tlily be seen in the jejunum, although the normal ileum tends to remaln fl'dtull'l""s. The calibre tlf the normal small bowel should not exceed 2.Scm-3cm, increa..ing slightly dhot,llly.

Often wry little is seen (If till' small bowel on plain films. ,1S ill Figure 1.1 , and it only becomes well visualised when abnormal.

16

The hollow viscera

COIlhn.-l

Barium pooling in fvndus

Gas in 00dy of stomach

Fig 1.7- This is a spal1iIm from a barium meal study with the patient supineeJl,octIy some paSltiotl os thepreceding film.

me

17

The hollow viscera cor>,inuttd took for the cppendix 'rou'Ilbclucky to find it!Occasionally this strurture w ill contain ,111 'appendicolith" [i.e. calcified fM'C.11 m.ltl'rial) which may predispose the pauem to appendicitis Lee, commonly ~.h will be pn....en t in the appt'ndi\, someurne, barium from a recent Gl st udy, or even piece, of lead sho t which have been ingest ec'! and Impacted themselves there. If you see this (Fi~. 1.8) you ran then have a Iittlt' bit of amusement with your patients, who will be amazed to know how you have figured out from their abdominal X-rJY that tlwy have rec ently eaten g.lm", (t'K.1 rabbit or a pheasant). Note: Retained barium in the appt.'ndi\ nnphcs the previous 'ldminblrd\inn of barium, either otdlly or pt'r rectum. and implies su- pected GI tract disease. If bar ium l'nh'rs the ap pendix. however, it implies that this mg,m is normal.

I Fig.1.8-Leodsholinopperldix 18

The hollow viscera con';n.-}

look for the colo n [Figs 1. I and 1.9 ) 1. Start with thecaecum in the ri~h l IliacfllS';'l. The-caecum ts the most dbll'nsib ll' part of the colon and rec eives tluid material directlv from tht' ileum th Rlu ~h the ileocaecal vain', The caecu m therefore nermallv contains semifl uid mater ial nmta i nin~ mulliplt' pockets of gJ.sand , like much of the right sid",of the bowel, assumes a gr,m ular ,1ppt>ilranCI' on X-rJYS, creating mottled a n ',lS of g.Js....-en best .lg,lin:-I the background of the iliac bo ne. On occasions the normal caecum rruy be l'mpty. 2. ,\8 The classic anJltl rnka ll,lyout of the colon j..; otten fnumi In ht> dt'\'i.lll't'! from by tortuous and red undant bo.....el, but the hepatic and splenic flexure, ..huukl be idl'nli fi.lblt' ,IS the highl~1 fhed fltlint" on the right and lett ..idl;"'>, n"'pt'cti\"t>ly. The tu n!,>\'t'!'>t· colon m.ay dip down dt't'ply into the pt'1\"i!'> , but lilt' faecal content of the bowl'! become, increasingly solid and formed as on,' pas"t's distally, eventuallv generati ng d iscrete masses which may be indi\iJually idt>nlifit.J, but which always contain m.an y tiny POI:k!S gas. 3. Learn 10 idl'T\tify faecal material on abdominal X-r.l}'S tsee Fig. 3.1 01. Find tlro t and you've found the ([I/,m, which m.ay be w ry important in film analysis, particularly in diffen'fltiilting sm.all bowel from large bowel, These findin~s can best No appreda red in severe «>nstif'iltinn with gnlSs faecal overload . Somt'timt'S thb "ill involve the rectum (which is usually t'ITlpty in normal iodi\iduals), when a 1.1~1' fat'Cal plug m.ay be present as...·..ociated with overflow teconnnence. .I. When visible the hdust ral fulds ,If the colon may be seen, only p.1rtially \isualin.J acn....... part of the Ia~t' bowel lumen, although in ..... une P.lti''flts Clllllpll'te en....sing of the lumen toy haustra m.ayoccur.

,.f

19

The AP e rect film Under the otfects of ~ravity much ch,ln~t>S wh en an abdominal X-ray ts taken in the erect posi tion . The m,l ~ ,r events ,lll': • • •

• • • •

•

Air rist's Fluid sinks Kidn c ys drop Transverse colon drops

Small bowel drops Bm1sls drop (f~'mall'S: they 1i... laterally when supilll') L ower abdomen bulge, and Increases in X-r,ly dt' nsity Diaphragm descends {"lusing increased cla rity of lung bases.

The liver and spleen, being fixed , ten d 10 become more vtstble, the remaining mid and lower abdominal contents It">s so. wbvn the lower abdomen bulge, under gr,wi ty this reduces the dartty of its rontvn ts owing tn th e crowd ing togeth~'r of 1'f1;ans a nd the consequent increased dt'ns ily of the Sllft tiSSUI'S. Depending on the I,ri¢n,ll lll'igh t uf the colon and their nwn decent in the "'TKI positiun, tIll' kidneys may become more or II'Ss visible. The erect film, however, I1MY now show flu id level.. (sl'l' Fig. 3_4), which can be wry helpful in con firming the didgnnsis of obstruct ion and ,1bsn'Ssl's, hut fluid levels on normal films tend to be \'ery small or invisible. In pcrforatton tlf the bowel an erect film may confirm a pncumoperuoncum, when g,lS has risen to the cla ssic suhdiaphrdgmurysms can luu k likeeach other. Note the age nf ('wry patient carefully. Premature calci fication in the aorta can be a very significant medical finding - t'_g_ in diabetes or chronic renal failure- and is nnt always due 10 physiological changes of ageing.

Calcified structures conlinved Calcified aor ta

I

Point of d ivision of aorta

Calci~ed L common iliac a rtery

fig, 1. I I - Supine APradiograph of a 68-year-old woman.

25

Ca lcif ied sn ucfures contotwe kidnl'y" before injection • ToIOllk fliT calculi • Tot'\c1 uJl' In aort ic d nl'ury~ m - compres-lon hy J light belt is otten applied acrose. tht- Iow er abdomen Juring IVU." hUI not in renal colic, oIhl'T acute abd('rnt>n,>, postoperative ~IJt~ or Irauma. The pUTpost' is to prevent in.ldwrtl'llt mmpreo-ion ulan aneurysm • To dt'Olt.ru.trdlt' ,IllY incidt'l\tdlfinJin~ • Tod'lt'd. the Tadiovaphic and pn..."\"!t.'Ioingquality prilll" to tlwocontra-.t injt'\:tillfl and t.Jking 01. turtht'f film.. • To b.j,;, for t"\idl'OCt' of meta..td~ in ..uspected malign.tncy.

27

Calcified strud\J res rotItintoed

fig . I.' 3 - This is Ifte supineAPradiograph ofa 4.>yeor-old mole who piesented with suspected Lrenol colic. Urologists refer 10 such radiographs cs 'KU8' films, for Kidneys, Urelers ondBIodder. Other names irdxie 'scour' films and'PRELIM' films, but thecorrect rodiogicallefm is a 'CONTROl' film. Th is means on X-roy token 10 cssess the potient before ony controst medivm hosbeen given. 28

Cckilied structures t;OtlImw Fig !i.l'lt can both create th is illusion, and these film must be remembe red . CllIlVt'fSl.'ly, true ht'patumeg,lly mus t be suspected when there is evidence {If displacement of adjacent o rg,lnS or, i1S d rough ~uidl" when 1I'll' lengt h (If the liver exceeds arou nd 16 em from the dpt'\ (If the right hernidiaph ragrn in th e pa rils,lgi ttal pla ne. b u t clinica l and radiological finding-, may not concu r, Liver I'nldrgl'nwnt is of WUf>;l' a very mm-~f".'Cific sign. and serves only as a reason for Idunf hing furlhl'r i n \'l'sligati o n~ of both hwr function lin d imaging - usudlly ultrasound to l>t.ogin with.

35

Big liver conh" ued

Tip of liver

leh kidney silting high

Fig_ 2. I - Abdominal rodiogroph of0 6B.yeor-old womon with 0 large palpable mOSl in the Rside ortheabdomen.

Look Jt

( Fi~.

2.1):

•

The hU~l' md~~ in the R side of the abdomen reaching to the lewl of the iliac

•

•

11k' absence of pit in the R side of the abdomen which has been dbpldn...:! Tnt' increased densitv of the R slde (If the abdomen

•

Tnt' rou nded contigu ration

C"-'!>I

Il f

the lower edge of tilt' mass

• Tht' l'n tin- margi n of the norma l R kid nt'y remaining c1t'olrly preserved sur n,un"li ng foil, indicati ng that the mass is not renal •

•

36

Th e R ma rke r confi rming this is wnsislt'nl wi th the liver The left kidrll'y sitting high tu pper m.l r~in n 11.

tty ib

Big liver cOtl,inV Illdy be tht' potential for recon .'I)' when Ihisfinding ~a!'..o;ociatt'\l with renal failure, although biopsy will be required for definitive d ia~nosis, almos t invariably preceded lly ultrasou nd to belp exclude renal ooserucnon and dSse-;S the parenchyma. Converse ly, sma ll kidneys usually reflec t end .....tage renal d i"t'o1'>t.' and an irreversible stall' , making biopsy somewha t acad emic and putentiallv hazardous.

•

Loo k carefully 10 0 ,It the edges of ttwkidlWYS. whether smoafh, lobulated or n regulae - important points in differential di,lgnosis.

Causes of bi laleral big kidneys •

Acu te glomerulonephritis

• • • • •

Diabetic renal diseolse (glomerulo·;clt>n",is) Adult polycystic disease Acute tubula r necrosis Acute cortical necrosis Bilateral acute pydonephritis

•

Leukae micinfiltration

•

Lymphomatous infiltralion

42

Big kidneys con r",ued • Amyloid • StorondJry I'm ,11 d i ~\N' in gout. • E\(~siw beer drink.i n~ - medical"tudl'nls I'II'J"'" noll'! Somt

uu~

of un ilollt'u l big Idd nt'y

Acuteobsnuctum Acutt.' inf.m1itm : I'\'fldl drtl-ry rcctu..ion, renal win thrombosis Acutt.' I'yt.'lllnt-phnli.. • lUdi.ltion rwphrili.; • Dupk-x s~...ten • Compl"lbdillry hypt'rtnlphy from contralateral nt'f'hl'\-'ctl>my (If dysfuncti<m

• • •

•

Rrn.al~.

Small kidn. s ~ing ltwo ~ l>f ..mallk.iJ~'$ may be \~. dlffJruIt or imf'l.... sibk onpLun filnb(lYoinf; tooverlying f,lt'CIOS ill1o.1 ~s. H,IWel.W. if the J'dtit'flli5 cll'arly Mn"t'.md not Ill'I di.lI\·5is th..-n- mu-..t be functioninp; M\a11bMJt> SllRk'wfwno. anoJ OC'Gbion.llly it b vbiblt.'. gememben The lidnl"p shrink. or dlrophy with age, compcnsatorv hypt·rtrorhy ma~' nlllllccur III Iht' ddl'fly, and X·ray measurements will d lwa~'5 grve .. :»-25 maf;nificali(lfl. so lhoil X-ray IDt.'a-'iUl'\"ml"Ilb will alwaY'" be Lugt'l" ttwn Sl1"t"> obtdined lin ultra..o cnd, CT or MRI examinations, fr.r t'U mpil'; IIX' if'PdT'l"nl Sill' Ilf the kid nt'Ys may also mcrease even moll' afte r i.v. co ntra-,l oIdmllu.'.tTation fill' I\'Us.

UUW'\ of smolU kidntys

• Chrome glllml·rultl'>Cll·n....is (u.;u.llly biL.lll'rall • Chronic i.'oChal"mi.l kg. n'fldl drtt-ry SII'f1llSis, drtl'rio~is) • Chn:mic pyd orlt'ph rili.. • Rdlu, nt'J'hnlp.llhy

• lniarction • St'llill' alnlpy • (ongl'n il.ll hYf'lll'lM.iil (u..uall~· unilatcrall,

Con g enital renal abnormalitie s NH Alw ays rem emb er that an unknown pati ent may have o nl y one fu nclioning kid ney, Thb i!> t"-pt'\"ially important when invt"!>tiRdtin~ trauma: mort" than one p.l til'nt in medi cal hish,ry has hod his only kidney taken ou t, and kid neys have a remarkable capacity for ht"l lin~ ,1Ild regen eration. ~ B A patient who is known 10have only one funct ioni ng k id ney And wh o is pAssing urine Cdnnol be complete ly obstructed. This is somcurnes forgotten by young doctors requesnng 'urgen t' IVUs for '? obstruction ' when rme kido l'y hac been removed.

Two importa nt co ng e nital re na l abno rma litie s Pel vic kidneys when inVt"Slig.llions fail to demonst rate kidneys in the renal bt>.Js, Olle or more tlf them is usually found at a lower level in Ih,' pelvl...This is called an ectopic kidney (Gn't'k ,'k, out of, ttl/JOs, place). Inflamed pd vic kidneys C,lO simulate appendicitis or gyn,lt'colog ic,ll probte ms. Rem ember: transplanted kidnt')"S mol Y be put into Iht' pelvis and even a norm,l lly sited Id d nl'y m,ly be invisible.

Horseshoe kidn eys These C.1I1 som etim es hi' sus pected or di,lgmN;'l.1 on plain films. Tlwy tend 10 lit' lower than normal and tend to I,Kk the usual medial mclmation relative Itl the spine .11 their uppt'r poll~. TIll' pathognomonic r,ldiologkal sigo is 10 WI' the rena l cortices of the lower kid neys crossing the margins of thl' IlSods muscles medid lly to connect with the etfu-r "idt' , This part of a horseshoe kidney system is known rlS the ist hmus. The d r,lin,lgI' sys ll'ms in this condition tend 10 be m..rlrota ted forwards. The isthmu.. may contain euher functioning "I' just fibrou s tissue. Look at (Fig. H):

• •

"

The cortical margin.. of the kidnt'y .. m~siog the p SO,l S muscle, The ,lSSl.lCialt-.J developmental spinal anum,lly ,1IIh(' Ll /4 levelon the ll'ft and the tt'm fdcing antero-latcr... lly in!>lt'dd of mt,Ji.111y"

Compliulion!O HtJf!ol'!;OOt> kidnl'Y~drt' mon- !ow>I.""t'ptiblt'ltJ infection, !otonl' formation ...nd trauma. TlJto holhmu!o m.JY a1o.tl gt"t in 1l14.' WdY in rdditilOOdPY planning" HtlN.oshtlt, lidtll'\"S 1J'\oI\' occur in TuTT'll"r's svndn>mt".

RInGI mau e , RrNI trId~'ol'S m.JY be ftlund during Iht>

inn~ti~h(ln

of a pdtimt "';lh UriIldIJ'

troJd !oymptnm..., such d~ haematuria, ur as an incidt"TIldl finding when Iht> p.1lil'lll ~Mng X-rd~'oo It)!" .;onwocht.>r purptl'>l'. e.g. bdckdchE-, but t'\"m d larp' orw m.J~'

lIP Ul\bihko en d Stdnddro. him"A sigmfKdnt M\dl m.JS'" m.JY

ht.lWt>\"t>r.

• IX'IVl1 the pt",ilivn t>l tilt.' dnlic1p.ttl,J renal t",Uinl' • Actu.1Uy d~spl.-.ct-Iht' lid~' mlm which itdn_ • Di.'f'LKt' tI\"t"rl~;ng ga.....contdining Iotlf'!' (I{ bowel •

Cn....!> the mdlme tothe tJppt"'itl' vide.

j-Lning dt'tl"Ctlod d m.J.... Iht> prlm.Jry rt'lIU1ll"llll'llt is Iht'n 10 t'!>tdblbh wht.:"tht'r it ill 'oll/id or C}...uc. and thiv can usudlly bt.> t'a~ily achwnod with ultrasound. Furtht"l"

urt'lul inspt'ctitln of tht' plain films in the initi.ll phase, however, III Illtlk for ll~" of pso.ls tlullint'" or buny d~tructitln of pdrt Ilf a vertebra. md)' indicatl' IN!i~ncy hum thl.' ooh...t" ull"king intn the lung ba_ on dn sbdorrunal X-rdY may also 1m ceca..ion 1\'\"1',11pulmon.m - meta..la......., a nd ..hould be routine on all abdomin.al X·rdy"wht'1'l.'lht""l' are vi..ible, althnugh d full rbc...1 X-ray will al",a dy be indicalt'ti. The nextta..l i.. ~Idging with CT 1,lthl' ma-s. MRI etc.

47

Renol moues conlirwed

Fig 2.6 - CIoHHlp view from obdominol him of [Honk in 0 56-year-old mole presenting with backache.

Renol messes

COI'Ih nued

This p..ltil'nt lR);_ 2.f1l initi,llly had hb lumb ar sp ine and abdomen x-rayed to look for a cause fur his bJd,al' hl·. Ap•art from minor dl1\l'nl·r.1tive change no ~I abnllnn.llity was found, but can- lu i i"-~f"'("tion of the film showed the edge of a large In.l'" in the It'll flank w hich was cle.uly 100 big 10 rep resen t part of a nOl11lJJ kidney. An ultra ...>U nd scan ronfirmed a solid ma"s arising from tht' Il'tt kidl'lt'~·_ On billf'!"Y this w a.. found to be a nm.al carcinoma.

\I oral: Do nol confine youl"'O(' lf to th e area o f p rimuy interest alone e n an X-r.y film. bullook ••• 11 of it. Alw.y be ready for the unespected Incidental finding.

A word about 'd isplaci ng mosses' {ll\~y

an .bnormal ma".. can an.... anywtwn> .00 it'> ~t'1lt"I"al effect will be eeseee. i.e. to produce a dt'll'>l;' area with disce.... 1J.t't" Fip ·U3 and -un The den..ily ul a mas .. may also be inrn"a~ by the f'l'l'Sl'N" at caldficdtion y,'ithin II.

49

Pelvic masses The urinary b ladder In p ractice tht' most common reason for findin ~ a la rgl' 1J1d"~ tin X-ray in the pelvis i" a full bladder (Fig, l.l), and ther e arl' a number of rt'.Nlns for th is:

1. Paucnts often han' to wait to be brought to X-ray and their t"ran"it molY be del.wed . 2. Further w,liling pt.·n ods o;sin' indentations in add ilion Itl the normal ones ("igmt.id ,lOti uterus! ca used by p'llhologicdlly l'nl'll);l-'d masses (('.g. fihJ'tlids) (' T faeca l overload.

Common caus es of p elvic mass es • • •

I'h ysinlog icall y full bladd..r: ma ll' or fl'mall' I'dihologicrl ily full blad d er indica ting outflow obs truction. ('.g. prostate in an "dull male or a blocked catheter in a female Bulky u terus (pn'gn,lncy) -111I,k fur fCl,d P.lfts' Did you check tlu- LMl' (1,1.,\

menstrual ~ritJoJ l bt>tnn' TetJul'Sting this film? The majority of slgntfkant abnormal pelvic ma sses occur in females, includi ng: • Leuun yomas - fibroid s, often calcified • •

Ovarian cysts - can be the Sill' of a footba ll Ova n an tumours (be nig n or ma lign.ml l

•

Pelvic infla mmatory d1>eo1 >;('/,Ibscl>o;""'"

•

Haemalnmetra (blood collect ion in uterus !

• •

End umetrtosis Haema toc olpos (blood collection behin d imperforate hymt·n l

•

Dermoids, containing f'll, teeth, hair.

50

Pelvic mosses conIi....d

Fig. 2.7 - AP pelvis: /VU examination, bladder area. Look at /he effed of a

ItUge pelvic mou severely compressing the bladder From above. This 00'0I'i0n cyst. It is alsoporliolly obslrvcting

was on

baf., ureret-s.

x on-gynaecologi cal • Al;>:;(t~ from dpr'lmJix, diverticula, lvm p hoc oete (rO"lnpt'rJliwlyl • Pelvic kiJnt·y Icnn~t'TlitJ1) • Renal transplant.

51

Re

'toneol masses

These usually ONUTt' the flSIliIS muscle on the affected side OT show a displaced fat lim' convex and beyond the mSOd~ muscle. They may show displarcment of tht' kidneys (see Fig. 2.Hl Of aorta. ,lfi' oft...n maligna nt, e.g. Iymph,ldenop.lthy, and n,!uin' furt her investigation. Do not mistake slight cunn-xily of the normally stratght pso;.liIS m,ITgins for pathology. These can hYP'-'rtmrhy in \"l'ry athletic individuals, just like the gastrocnt'mius muscles. Such Individuals lTh1y also shuw incipient degenerative cha nges in the hips in early adult life and medial deviation of the uren-rs on an IVU - signs to seek in confirmation, Look at lFig. 2,K):

•

eJgt' on the ll'ft sideand (lmWl

•

Theabsence(,f the normally ptlsitltlllN tll.1SS more lateral tn it Normal spit...·n

•

Upward and lateral displacement of thl' left kidnl' y,

fN>.h

This is TI'lwper1h>lwallymphadt>n0l'alhy, JUl' to lvmphoma.

52

r

Retroperifoneal mo sses cot1tittUed

Fig, 2,8- This is on lVU Mm showing renal excrejonina young man who presented with a moss in the neck, weight lossond backache.

53

Acute pancreatitis There art' no plai n film signs that co nfi rm or ex clu de ac u te pancreatitis. The d ia~ nusis is a clinic al one supported by high seru m amylase levels. Ches t and abdominal films will, however, usua lly hJ W been taken on admission wh ile the dia gnosis is being sorted out. Il1ldging th is condition and its complications is a jo b for ultrasound or CT, but underlying causes and seconda ry ef fects molY occdsilln,l lly be tderuified. l ook for:

•

Call-tone, Imay Ot' a pn..Ji!'posing fdctllr)

•

Calcification in the pancw,ls (chronic p.1l1cmltilis nMy be cumpllcated lIy MUT",nt bouts of acute pancreatitis ). Occasfonally ,1 tumour cont.lining calcificanon moly precipitate pancreat itis Pleural dfusiun s, b.1~1 dtt'lt'l:t,lSis, diaphragmatic elevation

• • •

Sign s of secondary Ileus R,m'ly in severe dtsease gas bubbles lll,l Y apf"t'a r in the panrn.'ols as abscess formation supt-'rv ent'S

•

Retnrperitoneal /;ZOdT Ifurball, wgl·tahlt' m,llh'r)

•

~l t·ld SI.l ses .

55

The stomac h confj,,,...J

Calcified lymph nodes

Extensive semi-digested load e nd gos in the stomach Iilling ml,lch of the abdomen

Fig. 3. I -A 5J-yeor-<Jld mon with 0 2.year history of dyspepsia wha presen,ed with l,Ipper abdominaldis/emion, 0 succussion splosh ond vomiting. This wos due to outflow obs/ruction ond retention of food residue and Ruid. A 'bezoar' looks similar - re'oinedvegetable maffer (phytobezoar), or hair in the stomach (trichobezoaror hoirball, morecommon in animals) . 56

I

The stomach eorohr,,-I Mo5S

of

food

in stomach

Duodenal bulb

Gastric fundus

Fluid level

Fig. 3.2- Same patient: erectview.

Gastric neoplasms Sometimes tumours m,ly be visible in the fundus of the stomach un abdominal films and chest X-rays, this bein~ an (II:Cpt'p.;,idl, hO\\'l'WT, pollients ca using corcem 0\'('( this ,1ppe,U,lnet> should bot- inn...tigalt'l.l .

57

Distended small bowel Small bowel pathology usua lly manifes ts itself on plain X-rays by abnormal accumulatio ns of gas a nd fluid, due to either functional (i.e. ileus) or truly mechanical obstruction. The main problem lies initially in trying to differentiate sma ll bowel frnrn large bowel. Once the sma ll bowl'! starts to dilate the sma ll irrt>gular pockets of g,h that may be seen nor mally increase ,1IId coalesce, so that eventually the interior of the distended loops becomes com pletely outlined in continuity where the lumen is not occu pied by fluid and com plete mucosal folds appt'ar. Remembe r: • • •

• •

•

The colon is peripheral and containsfaeces and gas The small bow el is central an d contains fluid and gas TIle more d istal the obstruction, tilt' mort' loops you will SCI' TIll' longer the du ration of the obstruction, the bigger the fluid levels Fluid levels can only be seen on erect or decubitus films, and small fluid levels can occur nor mally It is not lleH'Ss,l ry to be obstructed to have fluid lewis.

The stan dard series of films in the acute situation is a minimu m of ,1 supine abdo men and an erect chest X-r,ly. Exper ienced radiologists claim to make do with these dione, but most mortals art' reass ured by an erect abdomen ,1S well. NB Th e entire abdome n shou ld be vis ualized, idea lly on both th e supine and erect film s but certainly on the supine film s from the top of the diap hrag m to the hernial orifices in the groi ns, as these may be the site of an obs truct ion in an inguinal hern ia. But rememb er that the pre sence of a hernia doe s not prov e it is causing an ob struction. Two fil ms may be requi red in each position to show the entire abdomen. Look at (Fig. 3.3):

•

• •

The multip le centrally placed loops of bowel distend ed with gas The outlines of folds crossing the entire lumen in places The absence of ,lny flu id lewis.

[ 58

Distended sma ll bowe l conh"ued DiSlended loops of small bowel

Stomach

Fig. 3.3 - Thisis the supine abdominal radiograph 0/ a patient presenting w ith abdominal pain, distension, nausea and vomiting_Note absence 0/ fluidlevels.

59

Distended small bowel conlin..-J GoslJic flu id level

I

Small bowel fluid level

Fig. 3..4 _ This is thesome patient in the erect position. Nore new thepresence of fluid levels. 60

Diste nded small bowe l eOll,illu«l Thi~ (HI-':. 3.4) is tht' d,lssic appt'Mance of a sma ll bowel obstruction. The rrlativelv small number of IllI'f'S indicates a mid small bowel rather than .1 distal

"lI1.l11 bowel obstruction. The cause was adhesions from prev ious surgt'ry so me ~"t'.ars

before. In order 10 demonstrate fluid levels you need fluid, llwrly ing g,lS and a horizontal beam erect or decubitus film. Withoul the g,b you won't see lht' fluid! Although oosuucuon and pertoratton usually pTl'St'nt S\'p.udtt'lyand clinically JlIil'T\'ntly, alwayscheck til make sun' the patient has not sustained a pt.'rforation as a complication of an obstruction. This is ,1 ra n - but import.mt even t. SB The differential dcgnosts of small bowel obstructio n includes poualytic dftl, and it may be hard to differentiate between the two un r,ldinlogical grounds. ThI.'c1inical context is usually crucially helpful, ('.g. immediatelv postl1pl' r,l!iwly. Re member: Hoth gener.llizl'd and Incalilt'd ileus molY occur, t'_g theletter \lith 'sentinel loops' ad~1Cl'nl to an appt'lldh .I1:'sn'Ss. ~B

Cause, of small bowe l obsuucuon • • • • •

Pustopt'l"J by a 1.I1):;t' galbtlmt' impdcting in tht, ~t, u~ually at the terminal ileum wht'lV the bowel is rldmw.·""l. This occurs u~ually after fj~luld formation t.... twee n tht' gallbladder and the duodenum. It b QD('of tJw CdU~ uf intt">tilldl obstruction wht'!\.· the actual CdU~> lTldy be infl"fl'l'\i. l'nJLI!VIl.1Sl'd dnd untl\.'dl.>J it earn..... d high mortality Lonk fUT iRg. 35 ): \ lultlplt' dildll>J luop!> of ~1T\J1l bowel. i.e. o.'ntrdlly placed loops where tht' folds go right ~ I"'" lumen. Tht' colon l\"Il\oIilb normal. This indical~ '>U'IaO btlY..l'I t~tructiun . • The number til di..tended ItJl'p": the more there are, the more di~tdl the •

•

""""""""

.

Ga..~ in thebiliary tn..•. In thi... p..llil'llt tht't'I1til\' bill'duct i"OlItliooJand diloltt'\!.

Gob is ~I in the lumen tM tht'

~1IhL1dd("l".

However, largt'

~..able

qwntitit">of ga~ "ill notalwa)"s lit' rn_nt dnd onl)" in about a third otcase,

will the bile duct be lully di~p1.Jyl'd _ • The gdll..tore. Ml commonly thi .. i.. nol seen. but mAy be located in thtright iliac fO"Sd or uver tht' sacrum. It fn.qut'ntly consists of radiolucent ~erol "ith onl)' a thin cakifed rim , ITldking it hard to see, but in around til panents II ts ,"h.ihlt'. M tt~ t l*""tructing stones are over I inch 125 em) in diarJlt'tt"l", and may in fact be Iargl'l" than tht'y Iool if moll.' choIt">tt'fOl ha~ bt'\'!I dl'pt""itt'd bt-yond the cdkirwJ rim. If th.- p.!tit'fll was pmiou.Jy known to havehad a gdll~ttme in the gallbladder, look to see if it has ~ont' hum thdt jccenon.

' B\"0 ~tOl\t' was

\'i~ibll'

in Ihi~ pdtil-nl.

UU'>I'S of ga~ in th e biliary tree •

Pl't'\itJU~

•

lnstrumen tation, t'_g_"Rep / "phinCh'fillllmy

biliary SU~t'l")·. e.g. Whipple's operation or anastomoses III rhe gut

• Fistula forrrunon, t'.g. ~ll~ltlm' ileu-, • Posterior f"..rfl.ratilm lli In ulc•-r • Mali,l:n.lOt ~rll,',IJ to th.' bile du..t • EmphY"t'Tll.llllU" chn lt"'Y~liti~ (diJblotic-.1 • IAl\ sphincter (rhy~il>lo~ir,llJ. 63

Distended sma ll bowel con,inued Gas outlining gall b10dder

Gas in bile duct

Solid faeces in colon

Dilated small bowel

Fig. 3.5 _ GallsloM ileus This is a supine AP abdominal X-ray of a 55·yeor<JIcJ woman with a history af right upperquadrant pain, who now presents with more severe pain, fever, nauseaand vomiting. The X-ray shows distended smallbowel and gasin the bile ducts. You ca n also see gas in thegallbladder.

Distended large bowel Figures lb and 3.7 show a dbl'l ll'l rge bowel obstruction caused by a carci noma of the descending colon in an elderly woman who presented late w ith rectal bkoNing, weight loss and, Idtll'r1y, increasin g swelling of th e a bdomen. Colonic obs truction can ,1SSUrnt' a nu mber of ,1 ppt'Jrdnces, depending on the position of the obstruction and whether or notthe ikocacc al valve is competent. If it is.the caecum, being the mos t distensible part of the l,u KI' bowel, will distend, but if notthl' bark-pressure ....;11 be transmitted th rough the valv e into the small

00...1'1. and that too will distend, as in

it

small bowel obs truc tio n, but wi thout

caecal distl'IlSion. Dtsenslon of bo th of these pa rts of the bowel together can of cou rse occur withoul obstruction, owing to ill'us, and Isolated co lonic diste nsion ('colonic p5l!lldl>"Obstruction') may also occur assodated wtth medical conditions such ol~ Ml(myocard ial infarrtitlll). and thl' rad iologist may be as ked to exclude organic obstrucuon by run ning in some contras t medium retrog radely Th e critical diameter f(lrthecaecum is 9 em. beyond w hich it is in greet da nger of perforation. Look for: •

DiI,lIt'<J loops (>ocm)

• MJrked distension of th e caecum • Gmeral pt'riphl'ral position of bowl'! •

Several incom ple te ha ustra l folds, typ tcal of the colon, and a few complete ont'S- normal variation!

• Fluid faeces (III the Il'ft (erect film>, indicating colonic malfunction • Involvement dow n to the level of the descending colon • Alack ofdistensionof the small rowel, indic ating d competent Ileocaecal valve. 1\B Most colonic obstructions in the UK art.' caused by tumours (u p to

but in rau-e.

SOIllI'

f{I ~,),

other countries torsion of the bowel (volvulus) is the commonest

65

Distended large bowel COtl"nwd

Very distended caecum

Distended low lying Iransverse coloo

Fig. 3.6 -SupineAPlilm of abdomen. Female potienlaged 72, presenting with severe abdominaldistension. Nate the absence of Ruid levels. 66

Disjended large bowel «J(lhnued

LOfge fluid level in oKending colon Fig. 3.7 - Same potient ~howjng big Fluid levels in theerectposition.

67

Distended large bow e l conhn.-/ Cause s of large bowel obs tru ctio n •

Carcinomas (unlike the small bowel. where adhesions art:'the most common cause)

• •

Diverticular disease Volvulus - most commonly sigmoid and caecum (see below! in parts of the bowel with a long mesentery Inflammatory bowel disease te.g. Crohn'st

•

• • •

Appcndb abscess Metas tases Lymphoma Pelvic masses.

•

Ca uses of colonic pse u do-obs truc tto n (mdY require contrast study to exclude tru e obstruction and intervention to decompress caecum) Ml (with pulmonary oedema)

• • •

Pneumonia Mvxoedema.

Abdom inal hernia s Apart from being an intl'resting incidental finding, the prt'St'ncl' of external hernias is important because thl'y m,ly be the site of intestinal obstruction. From the diagnostic radiological po int of view the most sig n ificant application of this knowledge lit'Sin ensuring that when a patient presents with intes tinal obstruction the inguinal and femoral regions arc clearly demonstrated on the films - prt'fe r,lbly ill both the erect and the supine positions. If an obese patient has a strangulated hern ia in the region of the groin this may be d good way to help confirm it. NB Th e p resence of a hern ia in the context o f intestina l obstru ction dol'S not p rove that th e he rnia is the cause of th e obst ruct ion. However, if th ere is di rection al con tinu ity of a loop of bowel straigh t toward s a cu t-off segment of gut in a hernia, for example, tru e cause an d effect are most likely, Rem ember, if a h erni ated loop o f b owel does not con tain gas it will not be vis ible.

6'

Abd ominal hernias eonl,nued Scrotal hernias Appearance of hernias in th e groin

look for:

• Loops o( gas-fillt>d bowel e\tl'nding below the level Ilf the inguinalhgaments on both sides • Cuntinuityof I hl~ loops ",vith another loop in the true pelvis

• Enlargement of the scrotum 10 accommodate these loops (auscultation of the scrotum may render bow l'! sounds audible).

Fig. 3.8 - Scrotal hernias in 0 5Q.yoor-old monoThe X-fOY shows bilo'eral hernia foI"mo,iOll in !he groin, extending inta!he scrotum. This was on incidental finding and mepollem was nolobs/fue,ed 01 the lime.

69

Abdominal he rn io~ con'i"...d ulok
Consti

tion

Look for (Fig. 3.10): •

•

• •

The characteristic appearance of inspissa ted faecal matter - rounded masses of mottled or granular texture - due to tiny pockets of gas which they always contain. Find these and you've found the colon. La rger quantities of surrounding gas, with occasional haustral folds crossing part of the lumen and outward-billowing folds primarily in the periphery of the abdomen. The transverse colon may, however, be very tortuous and dip down towards the pelvis as it d ot's here. Formed faeces in the right side of the colon. This usually indicates constipation, as the material here is usually fluid. mobile and amorphous. Distension and loading of the rec tum and sigmoid (no t in th is patient). BUI these too Gill he grossly dis tended in severe constipation. In some individuals the colon may be distended 10 t ruly enormous proportions e.g. institutionalized patients who a re relatively asymptomatic but who pelSI' considerable anxiety when first x-reycd.

Causes of constipation • • • • • • • • • • • •

72

Painful conditions - aMI fissure, haemorrhoids Social -, irregular work patterns, hospitalization, travel (\ong f1ighls) Psychological - institutionalized individuals/defectives, depression Elderly - immobility, poor diet, altered routines Colonic disease - carcinoma. slow transit, excessively long colon Postoperative - childbirth, pelvic floor repair Paraplegia - autonomic dysfunction Drugs - analgesics, opiates, antidepressants, iron Parkinsonism - retardation Hypot hyroid disease - generalized reduction in bodily functions Chagas' disease - trypanosomiasis infection with megacolon Hirschsprung's disease, in children. In this condition look for huge mottled masses and gas in the surrounding periphery of the colon.

Ccnstipcuc n conlinued

Fig. 3.10 - Constipation This is a 55.year<J1d woman who presen,ed with increasing obdominal poin. distension, and camp/aiMs of reduced bowel Irequency Youcan seefoecol overloading in /he Jorge bowel.

73

The a

ix

Appendicitis is the most common acute surgical t'm t'f);t'IlC)o', but most appendices an' nut visible 011 abdominal X'fay.;. Often the dtagnose, and treatment are straightforward. but occol.;ion.dly difficu It or atypical pn'Sl'nt.ltions occur and under the,e ctrcumstaoce, abdominal films nwy he helpful. First check that ,my woman of reproductive dgt' b not p~nant. as appe ndioti.. oncn (l('(UI"S in lht' ~'Ol.mg, i.e. ask about the UtP: your patient molY have dysml'llIlrrhlll·a. ~B A norm al X-n y d oe s not exclude app end iciti s and no one rad iological s ign confirms it. How ever, wh en certa in radiol ogical signs occu r together in th e appropriate clini cal setting, the likelihood of appendicitis being th e correct dia gnosis grea tly Incre ase s.

A word about path ology Appt'Tldkitis is caused b~' blockage of the mouth uf tfus o~an with inspi~led faece, or a calcified rna..s lhl'n'ol Ifaeoolithl, k',lding 10 dish'R"ion and infection, .;umlllnding inflammatory reacnon, bowel sta ..i..and potential rupture - reflected over lime from t'll>rmality to t'SlJ.bli...bed rad iolog ical changes. Thi... mg. 3.1) is appt'nJicitis complicall'd ~. d~S tormanon. Look for:

•

•

Calcined f,1l'r olith.s. ThI'Sl'ffidyucrur ill normal f't"l'I'It'bu t alsooccur in Mou nd H 'l of p.1til'nts wit h acute appendicitis, and .I.; Ihl' y grow mdY t,l ~t' on .I laminated apJ'l',u,l I1CI'. Theyare different fmm calri fk d lymph nod ,....A duster (If four faecnllth s is I'n"it'nl here. M,I"S euec t around the appendix. The b!.IWI'lllIOPS are displaced alliolY h-om the pri mary focus of infection d ue to oedema , ruptu re end abscess formation, with walling (lff by the gll",ltt'r omentum - 'the abdominal J'l.lict·ffioln' .

•

74

De-tended loop!' (Ii bowel - 'sentinelloops'. The-e are du e 10 localizl'll ileus from the inflamma tion or matting wit h ad hesions, going lin ttl complete mtesnnal obstruction. It is the adjacent colon that is distended here.

The a ppendix COtlIiIl.-J

Fig. 3," - Localiied view of erect film of a potiellt with abdominal poin commencing centrally and then localizing to the right iliac fossa, followed by increasing toxicity, fever and a palpable moss in the lower rightabdomen and tenderness PI? on the right, 75

The appendix COftlinlJejo:ct in the right flank The black density of its interior.

•

•

This is g,lS in the lumen of an inflamed and tUl);id ,'ppt'ndix. It ts it rar e sign and must be interpret ed w ith cJ ution, .ls it TThly .l lStI occur in normal peopl e. Other r.1dil,logic.t1 signs tu took for in appendidtis include:

• • • •

Free &-1"> - a wry serious stgn of perforati on - either intra ",,'ritoneally or in the I1'tTllpt'rihllll'lIm (the ,1rpt'ndix canlie in either S!"'lCt'l, but this is ra re. u'J>,,, llf the right pso,a.. margin, but again this is ,l non-specific sign. Flexion or sl."o1iosis concave to the affected side. This ls natures WJy of relieving sp.lsm in the muscles on the pa inful stdc. It ma y also be seen in trauma or n'JIJI colic, but doesnot always occu r. Otber indirec t signs of inflammatinnyintra-abdormnal p"thotugy l"ausing h_s of clarity to thl' right properitnneal fat stript' in thl' [lank, Much is often made of this sign . But: This art',l shllu ld be included on abdominal films bu t often il is not , You will uftl'n need it tlrighllight to see it, bul often it is too dark 10see ,l nyw.ly even when the relevant a rea is included.

• •

O ther radiolog ical man ifeslatian s of the append ix

•

Remember that the appt'ndh may retain barium Imm a l'\'n'nt enl'md or oral barium study for m,lny weeks or months. Failure to fill docs not nl'Cl'S.;arily ind icatl'Jld that extrelumnul intraperitoneal gas is to No expected after surgl'ry, laparoscopy or pt'fitonl'o11 dialysis, so that the radiolugist must be given thl' relevan t clinical inforrn.rtiou and nol Ix> misled intu di,lgnosing pathtlll~Y incorrectly as ,1result of failure by the chntoan to provi de it.

Abnormal gas •

con~fliJf!d

Conversely after ,In iatrogenic procedure such as endoscopy extraluminal g,IS should not be expected, and its prl'st'l1n~ in tha t situation indicates a catastrophe, i.e. perfo ratio n of the gut. Th e pro cedu re need not have been technically d ifficul t for thi s to o.. . cur.

Pneumoperitoneum

1

The radiological signs of a pneumoperitoneum are among the most important signsin radiology, indeed in medicine. Somettmes the amoun t of free g,lS is sma ll and you may have to work to demonstrate it. Miss it and the patient may die . t ook for: •

• • •

Bilateral da rk crescents of g,lS under both bcmtdaphragms. NB Figure 4.1 was taken erect, so the gas has risen . This is a large p neumoperitoneum , but small amounts of gas require time to rise to the subdia phragmatic position so it is a good idea to leave the patient upright for 10 minu tes toallow this to happen before taking the X-ray Gas may appt'ar on one side of the abdomen only, usually the right No gas may be seen if the perforation has been scaled off by the omentum If only a small amount of g,lS is present it may be missed unless the film is centred at the level of the diaphragms - usu,llly a chest is centred around the fourth thoracic ver tebra. With at tention to de tail as little as 1m! of free gas may be demons trated.

87

Pneumoper itoneum

COfllinved

Fig. 4. I - B.L Erect CMsl film. 6O-yeor<J/dpalient with0 hislory oF uker disease, presenling with acule abdominal pain and boarcJ.Iike rigidity in the abdomen. Note the bilateral radiolucen' collections of gas under each hemidiophragm. This was due 10a perforated duodenal ulcer. There isalso a moss in the left lung.

88

Pneumoperi toneum

«>nlin..-i

Supint'films will usually have been taken mutint>ly with tbe erectones.and certain JnOl\'subtlesignsof free-gas in the peritoneal cavity have been described to enable thediagnosis to be established under these orrumstaeces. LOllk for. 11Ie double-wall' sign (Fig. 4.2), i.e. bot h stdes of the wall of loops (If bowel become visible because of air on t il l' inside and air on the ou tside - try to find an isola ted viscus surh as IhL' stomach Of bow el loop, but remember that c1O!'ol'ly apposed loo ps m,ly give J false positive 'double-wall' sign • ' Football or d ome sign'. With a l,u ge pneu moperitoneu m the und ers urface of lht'di.lphragm may be-surround ed by air,giving a darkdome-like apP'-'drdnct' in the uPJX'fabdomen even on supine films • visualization of falciform ligament - 'Si!Vl;'T'S sign' t Cas in Ilk' scrotum in children • Inseriouslyill patients theu~ of erect films may not be possibleand decubitus films with the left side down centred on the right u ppt>r flank should be taken.

•

Bri!\ht lights m
anastomosed to the gu t to fill them with COl a nd monitor their subsequent size - a form of 'coca-colagram'; thereby avoidi ng the risks of iodin ated contrast. UllJd".mnd would now be used, howev er, and can de tect gils by brigh t echoes coming from the bile d ucts.

Gas in the wa ll af the gallbladder Asopposed to !}IS in its lumen, g,15 can occu r in the wa ll of the gallbladder itselfso-called 'emphysematou s cholecystitis'> d ue to infection wi th gas-forming organbms, especially in d iabetics. It look... similar to gas in the wa ll of the uri nary bladder (Sl'l' Fig. 4.12). Other Ih,111 those slated on page 63, causes tlf gas in the biliary tree includ t>: • • •

Crohn's dtseese

Pancreantis r.uasi tt'S, l'.g. ascmasts .

103

Gas in the urinar tract As with gas in the biliary tract, the findi ng of gas in the urinary tract usually indica tes recent instrumentation or else something serious ~oin~ on, such as ~as­ forming infection or fistul a forma tion. Causes of gas in blad d er lumen (see X-ray nn p. 182)

•

latmgemc, e.g.cystoscopy

•

Out' to fistula form.mon.

Causes of bladd er fistu la • • •

Malignancy of bowel, bladder, genital system Cro hn's disease Diverticular disease

•

Po stoperativ ely (controlled trauma'}

•

Trauma (uncontrolled}

• •

Radiotherap y Foreign body

•

Ulcerativecolitis.

Note (Fig_ 4.9); • • •

104

The distension of both collecting systems from the obstructing effect of the bladder carcinoma The white outline of the left renal collecting system by contrast medium - the usual 'pos itive con trast' from the i.v injection The blac k ou tline of the right renal collecting system, i.e. ' negative contrast' from intrapelvic and intracakycal gas on this side, plus the non -fu nction of the righ t kidn ey.

Ga s in the urinary trcct COIl,ill.-l

Fig. 4:9 - Gas in thecollecting system. This is the Film of on IVU sequence From a pahenl with 0 corcinomo of the blodder who, in addition to hoematurio, complained of possing 'Foam', with bubbles in his urine. A Fistula hod formed with the bowel, ollowing gos/o enler the bladder ond the rightureter,

105

Intramural gas H,wing assimilated the norton of gas as the body's natu ral contrast agl'nl for the purposes of diagnusis within the bowel. and evidence of the wry serious situation of t"SCape and leakage from it. it is now nl'«'S..y.ry to recognize and understand the significance of gas in the W illi of certain stru ctu res, where it may {l('('asionaUy be found Isee below) , e-g- the bladder, Intramural gas may appt'ar virtually anywhere of course, but in practice a c ommonly important place to look for it is the colon, I'.g. in chil dren.

N ecrotizing enteroc o litis

Look for (Fig. 4.10): •

• •

Intramu ral colonic gas, especially on the right-hand side - note the d,uk margins forming a connnuous track A normal appearing loop of bowel in the left flank with a normal wall of softtissue d ensity contras ting with gas in the lorren Cardiac leads. Moniilm ng of the child n>t1t'C1s the severity of its condition. The child has also been intubated tnote the endotracheal tube).

There are many causes of intramural gas, a list of which is given after several mon' examples (page 11 0).

106

Intramural go ~ conlin.-J

lnlromurol_

9"

Fig, 4.10 - A young infant presenting wi,h prostration and bloodydiarrhoea. Note the veryclearedge ofthecoJon outlmed bygos in the wollof thebowel. This iJ necrotizing enterocolitiJ.

107

Intramu ral g as

con'i"UfId

Pneumatosis coli Look for (Fig , -1.111: •

Ga"C)'.,ts pmtruJing inlo the lumen of the 1aJ};t' bowel causing a mulliplidty

small pockets, far in t'1la'SS of normal in the right uPJ't'l' quad rant Di..tornon of tnt' normal mucosal pattern Evidence o f perfora tion (not present here! - this may be locallzed or gt'neralized, i.e. a pneu moperi toneum. or track i n~ into the mesentery. The-e 'pop pmgs' of the /;gulaT lucent

I Fig, 4.12 - This is thelower abdominal X-f0Y of a 50-year-old man w ith severe IIrinory trod infection. The pohent was diabehc.

109

Causes of inr,.cmurcl gas

Common •

•

Inf lammatory bowel duea..... -mily be a ~i~nof impend ing f'l'rfuralion in toxic dilJ.tJ.tion of the colon, J.complication of ulcerative colite, lschaermaof the bowel causing incipient nt."OllSis/infJ.rction, JUl' to. strangulation

volvulus

•

necrotizing ffitt'rncolitis obstruction [premature infants) l'neumatusis CYSlllidl"S. Usually benign. Onen ,In inddl"Ilt,l l finding on X-ray (p. l Oll).

Rare • •

•

Diabetes with infected gut wall (J.ISll g,lllblilddl'r and urina ry bl.lddl'r) Iatrog enic (post l'flJOI'CUpy, biopsy surgery) Obstrucnve pulmonary disease tradun~ down from chest (.l~lhl1ldtics, CDI'D patit'nt5)

•

Pt'plic ulcer diSl"dSt'

•

Peneeranng injury

•

Steeolds tmav be stlenn.

110

Intra-abdominal infection Approach to the problem A vt ry high indt t of susp irio n must always lit' maintained for the ~~ibility of intra-abdominal infection, especially in pt ..... toperanve patients who do nut recover quickly aner surgl'TY. This is also true for patienls who all.' ju!>t vaguely unwell but pyrt',ial on admission, as well .IS tho!>t.· with localizing signs. Common major ronce ms are the subphrenic abscess after su rgl'fY, and pericolic abscess formation from rupture (If the ap pendix or an infected colonic divertirulurn, although these will usually N' accompa nied by pain. Penetrating injrries are also a potent SOUTCl' of transfer of ba cteria into the a bdomen (knives, bullets etr.I, causing peritonitis. Abscess formation lead s to pus, and a l.ugl' liquid collection m,ly be readtly detected by ultrasound (If CT but remain only as a vague mass dl'nsity Of even undiagnosableon plain films. In the presenceot gas-forming organisms, however, tither multiple small bubbles Ofabnormal larger collectionsof gas and fluid may mabk a plain film diagnosis of abscess formation to lit' suspected , and indeed thegas thus formed may block acoustic access and render the plain film superior to ultrasound for diagnosis in this regard, but no! CT. wteo en abscess is forming in a ca\ity the semisolid materia! milled with gas bubbll'S may give it a granula r texture like faeces, so caution must be exercised heft'.Agood clue to the prt'Sl'flce of an abscess is the constancy of its posjtl on , so 'look for the gas that has not moved' on serial films. Try to gl't vrcct Ofdecubitus films with the affected side uppermost, in addition to supine films. Normal gut undergoing peristalsis cau ses changes in configu ration minute by minute, although ileus may complicate the situation. Sentinel loops may m in an arM,. beoing defmed a!> loss of parallelism in its w alls . OnlYOlK'of the two w allsof a tortuous but parallel-walled aorta Illdy be visible - usually on the Idt. 1IIl.lking like an anWl)'!>m w hen one is not rn~'fll. A true aneurysm may haw one w all bulging to the right of the spine - get used to looking for it hen' as well.

•

Rarely some am'Ury!>m~ are so large kg. > 8 em) and their calcified walls so far apart and atvpfralthat they go undetected if the observer is unaware of this phenomenon, ur they may blend with the sac roiliac ~li nls tow er down.

• •

Musl ant.'Urysms an' asym ptomatic. Vt'!')' rarely the-superior rnesen tenc artery may caki fy and, taking a long curved CUUN 10 the Id l of the -pine. may simulate an aortic ant'UTysm . In this situation . ho w ever, the aorta itself is likely 10be ralo fied and should be visible asweD. look at (Fig. 6.2):

• •

The thin rim (If calofxanon 10 the left of Ll and distal to it The even more subtle rim of calcification to the right of 1..4 adjacent to the lumbar spine.

The patient had non ·op,lque ga llstones . This was the typical incide ntal radiological presentation of an abdominal aortic an t'urysm. or 'triple A'. It was missed by the first two doctors who k-..l"l>d ,1t lht' film. Look at (Fig. 6.]) : •

The unequivocal fO(,11 expansion of the calcified wall of the abdominal aorta, confirming the prl'Sl.'flCl' of an ant'urysm.

~B All ilTldg~ on X.ra ys are slightl y magnifit'l..! and thi.. tndude, olnl'Ul)'slmo, but aortas O\'!"T 3 em are usually ~nJt'\l .I .. allt.'Ury~lTIdl . SOITlt;' aortas can be » em in diameter [so-called 't'Ct.1tic'l, but Nt" Jnt'U.ry"1TId1. "0 Illtlk for departures from parallelism, i.e. l(lUl at the ..hare III the aorta.

121

Aortic

o neu ry~m~

contonued

Fig. 6,2 - This is the supine APradiograph o( a patienl X-rayed (or righl·sided abdominal pain. The firs t /WO doctors missed Ihe aneurysm.

122

Aortic aneurysms

conhntlfKi

Fig_ 6.3 - This is a lateral view of the some patient. The third cJoclor who sow /he previous Film was suspicious and requested this further view, confirming me diagnosis. 123

Aortic a neury sms cOII/iroved

What To 0 0 7 A~

in m ,tn y other situations the answer to the radlologfcal problem lies in

requesting further views. Do nul struggle on with just one film if you .H~ not sure what is glling on, but it is best practice to seek help before r..... irradiating the patient u nnecessarily. Ho wever, if you are alone and still unsure you may: 1. Req uest a lateral view of the abdomen. This will get the aorta off the spine and you will have a clearer mental pic ture of what you are looking ,H. 2. Req uest a su pine left posterior oblique view (" right anterior oblique view). Th is is often superior to the lateral an d givt'S an excellent dew of the aorta in isola tion from the spine, although yuu may find it harder to in ter pret. Radiologists, however; find this view extremely valuable. The solu tion to the possible pres ence of an ,lIleurysm may therefore be solvable with plain X-

rays, but ultr asou nd or abdominal CT are Ihe next investigations of choice. Is it leaking? An early decision must be ma~e with an acute abdomen as to whether to proceed stra ight to theatre or whether theft' is time to Image the ao rta, even with plain films, Are the rena l arteries involv ed ? [f the i1nt'urysm extends as high as L2 this is likely, but accessory renal arteries may be present at a lower level and can never be excluded by plain films. CT ,lIlgiography, magnetic resonance angiogr aphy or con venhonal angiography may be l1l'Cl~sa ry to confirm or exclude these. Look at (Fig. 6A): • • •

The irregular convex edges of calcification 10 the right of the lumbar spine The clea r righ t p~(las margin Loss of the left rSO,l~ ma rgin and increas ed soft-tissue density on the left side with a convex edge further out 10 the left.

Th is is a leak ing abdominal ao rtic aneurysm, with a haema toma accumula ting in the retm per iton eum on the left side. NB Clea r ps..lilS margins do not pnw e case , but 111,>t always ',0, and an iliac a tendency to ruptu re durfng prl'gn.mcy, with a ditfl'll'ntial diagntl'>isof a 'ru ptu r edectopic' and a high Illllrtality. They hepatoma Secondary liver tumours, e.g. colloid carcinomas from the collin, O\"lry or stomach Hyda tid cysts with fine lines or contracted 1'l.l gl'S if partially collapsed: the 'water hly' sign.

Calcified g a llbladder. ch ro nic c ho lecystitis

Occastonally the gallbladder itself may calci ty - ' porcela in g,lllbladdl'r' - or the hill' within it maybe (If high density - 'timey bill"

-c

both these rht'0I1mt'M being

associated wuh chronic cbolccysnns.

Fig. 6.7 - A 59-year-oldpotientwith /ine stippledcaki fication in the liver. This

was secondary tIImour froma colloid carcinoma of the colon. Note the ossocio/ed elevation of me right hemidiophragm due to liverenlargement.

130

Splenic cakmcation Calcification in lht' spleen is an OC'C1' allnf the gland , "'II is nul d reliable predictor Ili prust,'lk size. 1'nl'.t.llk (,llctfic,lliun is Mt pn-,(ilnn'wus in il~.'lf. but it dlll.~ nllt exclude m,dignolncy in anoth..r part Ilf thl;' gland. ThO' main differentia l I!> from d urethral ca lru lu.., which is u..uallv midlillt." in f'O"ilion. uniformly den-e. ..mooth and ....lI1ldry Do not mistake the en-face soft-tb..ue ..hadow III Ilkpeni.. for a cdkifil'\i bladder shmt', rn~t.ltl' OTureth ral stonl' (.... Mi..l.·JlhnK imJgl~ and drtl'ldl1.., pd~e 17M.

·t·

Hint: De not mi..tdkl· d melnng or wry small. Their appea rann- may be

\'t.'ry variable Evidenceot a laminated or fMrlt'd structure, i.e. concentricrings llT polygonal ~pt'S Jut' to abutment of stonl;'!; one upun another hidffiCt" of co-tat cartilagt' cakification/l\"ILJl stone formation on both sidt'" of tho! abdomen which may be mistah'fl for bilidry calruli ..... hen seen on the ri,l;hl. But remember that renal and bil iary stones can coe xis t, dod the gallbladder Ii6 in frunt (If the ri~h t kidney.

Gallstones

1A9

Biliary calculi cor>h"u«J Help ful hints

• • •

• •

Ask for d prone ob lique right upfX'r quadrant view. This will often Isolate

calcuh in the gallbladder, especially if they art' near the spine, and abo cut down scatter from J full abdominal film, giving beucr clarity and contrast. Look lower down than just the right upJ"-'r quadrant. The gallbladder mdY be low-lying bccauseof ,1 big liver, or b eon a wry lung cysticduct , Occastonallv it m.1Yeven lit' in the pt.'lvi;;, A lateral view may help, as gallstone, will tend to lit' anteriorly and kidney stone, posteriorly, but the film must N' suffkil'ntly penetrated. An erect abdomina! film m,ly caus•.' small calculi III undergo 'I.lYl'ring', i.e. til form ,1 small horizontalline as they flU'll in the bilt', The gallbladder m.lY be contracted, however; and prevent this fmm h.lppt.'ning if dL"'t' both c.I rd u ll~v and. if 1Il'n 'Ss.U') ', !/;t'l them both imaged. An early triage of the p atiem will of COUN' be m'(t"'~ry to de termine thl"I'ltost seqUl'fK1.' of im 't'!>ti!/;,ltiw procedure, but each trauma centre will h J W its ow n protocol. In evalcanng x -rays for abdommal traumalook for: •

The p,llit'lIl'S name. Establish ,b quickly

olS

po..~ibll' the

p,l tient'~

identitv fnr

bothmedical and medico-legal reasons. Unconscious casualties m.1Y initiallv have III be labelled .1S ' unknown' or ' Mr X, Get the name on the films as soon as possible as mu ltiple 'unknowns' nld~' cudden jv flood in, e.g. after J major molorw,ly accident or rail era-h. lm din!/; 10 potential mix-ups, The lime of the film h',g . lJO pm t. Multiple '#.'ri,ll X-r,tys molY be required following admiss ion ,1111.1 the subsequent tempora l sl't1ut'nce milY be importa nt in follow ing events. ,101.1 thl' .lollI'S on ,111 the films willbe the s ame, unless thl'Y cruss over midnight. Also • Chec k what is left and right. Do not mista ke iI norma l liver for an injured spleen by failing to do thi .., or miwi,l!/;ntl'>t' !/;as under tht' ' rig ht; berm•

157

-

Abdominal trauma «lII~nlldd

diaphragm from seeing it normal ..tcmach Oil ,1 film you h,1\'1;' put up h.ld. to front. (Null' how frl'lllwn tly they dolhb Oil medical TV "'Mp", ,10, Sl'Hliosis 1'\lI\C,l\"1' totht' inju rtoJ sidl', ,111.1 e\"id..nn' ni btul )' injuri~ in tht' Ill\w nnlJ!;1 ribs.

Abdominal trau ma conli,.1lftd

u

"

•

Be aware that trauma can cause secondary ileus and a l,lrgl' accumulation uf ga~,

which call int~rft'I\' with trauma asses..mcnt. Dispbn'ml'nt of holh ....v organs, ",.g. the stomach med ially ,\IlJ down ....',mls with an l'nl.uging spleen, or upward displacement of small bowel loops nut of the rl.'1vis with a ruptured bladder, Check abo for an overloaded bladder and catheterize the patient, if not ,'llft',ldy dune, III rdil'w Ihb and monitor

•

n

,

"

F"-I!'>~ihll'

r

h.remaruna and urine output

sub~'\jut'nlly.

Flll\'i~n

bodies, "'.g. buill'!" in the USA and lither countries where gUll!> ,lIitis m,ly often be unrovered hy CT, and colour Doppler aura-ound m,ly conttrm or exclude j.ll'rfusiOll of org.-ms and limbs. The head , rhl'sl, abdomen and limbs ran bt, r,lpiJly scanned in ,1 sri r,11 CT machine, although l~st'llti,ll imrnnbihz.ttion/anae-thetic devices m,ly slow things down d hit. f..l.rly rm~I't'SS to evcreuon unwarhy, un'thn~rarhy or artl'riography m,l~' hi> an urgt'nl and nece-sary follow-nil from plain X-ray" in the cveluauon (If trauma. \ fRI m,ly be urgt'llt ly required to assess Srin,lllrdUm,l. 0 0 nol unne cessarily tak e out a patient 's fun ctioni ng kid ney: he may onl)" have the one, You must make t'H'ry dfurl ttl establish the r~'nn' or othl'rwist>of another wnrking kjdnev before Idking out tht' only one he or she h,lS,and rem ember tll.ll kidneys h,I\'I' remarkable ptlwl'r" of rt'gt'nt'r,ltiI11l. And wnsidt'r this for ,my injufl'll kidnt'y : '\Vnuld l ctill t,lh' out this injured kidnt'y if I knew it w,l" thl'nnl~' one?' 0 0 nol wacte lime with imaging if th e palient is bleed in g 10d ea th in fmn t of you . Rc-uscttation mu-t come fir-t , and after that in "omt' r,lst-, immediate

159

Abdomi nal tra uma con bnved transfer to theatre may be required , and if nl'Cl'Ss.lry X-r,lYs undertaken only then .u the discretion of a senior doctor.

Trauma : rcpn ned kid ney Noll' (Fig. 8.1):

•

• • •

The swelling (If the right kidney The t'SCapt> 01contrast trorn Iht, right a,lll'Cting system, indicating rup ture of tlu- kidnt'y. A I,Uj;I' volume of hh ...Jd is escaping as well. The scoliosis concave to the injuft'd side (ind irect sign) And most imrnrt,mtly: another normally (,ll.cn'ting kidney . >1\ the opposite side .

Footnote : Escape of ('onIT.1S1like this can occur in severe rena! obs truc tion ill the acute setting.or also in the chronic Sl'tting where ill-an form a huge fl'lfllpt.'ri lont>dl flu id conecnon called ecting aorla •

Pulmonary embolism etc. m,ly all m asquera de as an acute abdomen.

177

The acute abd omen

con~n.-J

Remember also that tht' r.ldioll1gical signs may not be present or fully evolved attbe time of presentation, so if nerr-,"'uy re X-ray the patient afteran hour or so, or move on rapidly to ultrasound, CT, IVU, angiography or whatever is appropriate to ~t,lh1ish the diagnosi.. withou t dday. Ora l water-soluble contrast or recta l contrast may bot' given 10 confirm or exclude visible t'\idt'nn' of leakage or obstruction in appropria te circumstances. but thb should only be after diSl"Ussion with the radiologb;t. Remember also the many cau sl's of acute lower abdominal pain due to g)'nal'colt>gicaldi!'o(ll\h-r- in women. e.g. dysrrwnorrhoea, Sdlpingitb, ovarian . Film~ can "d~ily gt'l in the "TOng f"ld.t1~!

~'OU

•

Check male or It'milk

• •

Check ldl and right. Makt' sun' l'n-rything is on the film, trom the bcmidiaphragms to theinguinal

•

canals, or covered by Sf.'\'t>fal film... ~ Idk{'sul\' you under..tand bow the film was taken, te. erect, supine.decubitus.

• •

• • • • •

•

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Of oblique, and 1M! yuu understand the implications of each position and what to evpect . e.g. fluid levels do nt)l: i1Pf'l'ar on surim' films. You see what you Ill1l1.. Ior - don't underestima te the 'mark 1l.')"cNU'! In acute abdomens always gl>t a chest X-ray, prdl'rably erect. Remember thai ~ous Chl~1 ueea-e 11'Ld~' mimic serious abdominal disease, and vice versa , ~OnJdry X-Tdy ch.Jngl-.lo abdominal disease lThly occur in the cbesr. Cht'CkIhl! lung base, and luu!.. fur the breasts on abdominal films. Find the tee-e, a nd you've fuund the colon. Acquire previou-, film!' a~ soon ol~ pu·.siblt' to rompare with new ones. ~lol!..t' ..un- you've put rhe film up the right way round! Only view films under prtlpt'r conditions of illumination, i.e. on a \it""ing box, wa\in~ them in Imnt of a window on 01 ward round ....ill guara ntee Yt1U will mi....20'{ of what there is to see. Put a bright light beh ind any area too ddr!.. to eee properly on the viewing box. Sod's WI'.' will always conceal a sign ificant abnormality in a wry da rk area e.g. rib frartun.... Y"U must be abletn exp lain l-'\'t'I),thing yuu see o n a film in terms uf anatomy, fI,u ly. 'Not hing l'~cl u dt'S ,lilYthing' i.s 01 good working aphorism. Life-threatening 179

Hints con'inved

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iIInt">S mdf be pr~'nt with no or onl y J few radiological ~i~n~. R ules Me for the obedienceof foob and the guidilncel1f wise men'. l.c. do not stick ~liI\'ishly to protocols. Adju ..t f our actions ilppropriJtd y til the patient's

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prtlblt'm~, and keep a globdl vtew of the patient at all times. when in doubt, do tlK> right thing_lilt' ca lling a radiologi..t at 2 a.rn. 'Every woman is pregnant until proved otherwise'. Gt.'t the LMP before

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1"l't.JuI...ting X-rd~~. Keep en opt.'fImind , Remember the Omcl'p1 of differential diJgnIJSi.., Do nilt be boxed in by otht.'t pt.....ple,' "U..f't'CIN labels and diagnc......... Le arn to work out the ilgt' of patients from the dpp"'ilTdtlCl' I" tht'ir films (i.e. fn>m vascularcalcification, dl~l'T'lt1'ilti\"l' "pil\ill changes. curti("althinnin~ times of l'Pirhysml closure etc.) , and cross-check it with the date of birth and the date the film was ta ken. M,lint.lin J sceptical outlook Oil all d,lta supplied. l;.'lt / right markers can be incor rect and the wrong names gt'! lin patients' films. 'Check fur An",s error.' 'tour p.llil'nt may deny previous SU!"HI'ry bu t han' Win.' su lu rl'" visible. Have you got somebod y else's film in yo ur hand, or is your patient demented ? Learn to look, th ink and .utku l,lll'/discuss the findings o n X-r.IY films simu lt,ll1"ously. Th i.. take, m,my YI'.u's to perfect, bu t nnw is the time to ..tart. Minimise the rad iation dl""l' h' p.llil'nt" by tilking no mort' films than nl'('t'Ss,ny.

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To '*'t' fluid Irt>eIs you need fluid, ,11. Do not waste time with abdominal X-cays in crincallv ill patients. If ind icated, go siraigh l 10 abdominal CT ~anning or theatre for immt'dialt' surgical mtervennon re.g. ruptured aortic aneurysm).

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Do m>l sit rock a nd wail tor somt.'thing to JUmpnut at you from the film dod if mllhing dOt'!> "'ll ra il il 'norm al'. warn the rdd il,logiral sig ns of abnormality then go looting for them Milk Ihe film YllU'W got bdon' dsk ing for another one. TIlt' d iilW1IJSis of norma lity is an important co nclusion to em ve at and is the