Chest X-rays & Abdominal Plain...

Chest X-rays & Abdominal Plain Films…

Shervin Rafie, MD

Check List

Identify Film: patient name, date and study

Inspiration: 9-10 posterior ribs above right

hemidiaphragm

Position: upright (gastric air-fluid level)

Exposure:bronchovascular structures visible through heart

and diaphragm

Rotation: line through spinous processes bisects line

between clavicular heads

PA vs AP PA: clavicles appear lower, scapulae project more

laterally, posterior elements of vertebral bodies clearer

AP: magnifies heart

PA AP

Chest X-Rays: The Yellow Brick Road

ABC’s…D & E

Air: lungs, including central airways & pulmonary vessels

Bones: ribs, clavicles, spine, shoulders, scapulae

Cardiac: heart & mediastinum

Diaphragm & pleural surfaces

Everything else: lines & tubes, upper abdomen, soft tissues

of chest wall and neck

Air

Air Space vs Interstitial disease pattern

Air Space/alveolar disease pattern: aka consolidation

Fluid density in alveoli

Signs: inhomogenous, patchy opacities, air bronchograms (bronchi surrounded by opaque alveoli)

Causes: usually acute/subacute- bacterial pna, cardiogenic & noncardiogenic pulmonary edema, aspiration, pulmonary hemorrhage

Alveolar Disease

Air

Interstitial Disease pattern: aka

reticular/reticulonodular

Fluid density in interstitium

Signs: diffuse white lines throughout lungs, with or

without tiny white nodules

Causes: usually subacute/chronic- pulmonary fibrosis,

sarcoidosis, Metastatic carcinoma (lymphangitic),

occupational lung dz (abestosis, silicosis)

Exceptions: cardiogenic pulmonary edema & atypical

pneumonia (viral, mycoplasma, miliary TB, histoplasmosis)

Interstitial Disease

Mycoplasma pna

Atelectasis

Causes: obstruction (tumor, foreign body), compression

(pneumothorax, pleural effusion, traction (scarring)

Signs: displaced interlobar fissure towards collapsed lobe,

displaced diaphragm or mediastinum towards collapse,

decreased lung volume

Plate-like atelectasis

Atelectasis

Pneumonia

“Silhouette” sign: obscuring of border by lung infiltrate

Heart border = right middle lobe or left lingual

Diaphragm = lower lobe

Air Bronchogram: bronchi surrounded by fluid filled

alveoli

“Silhouette” Sign

Pneumonia

Lobar Pneumonia

Causes: Streptococcus pneumoniae, Haemophilus influenze,

Klebsiella, Neisseria meningitides…

Signs: lobar opacification/patchy fog, air-bronchograms

Lobar Pneumonia

Pneumonia

Bronchopneumonia

Involves bronchi, bronchioles and adjacent alveoli with

possible volume loss

Causes: Staphylococcus aureus, Gram negatives, mycoplasma

(also interstitial pattern)

Signs: segmental opacification, no air bronchograms

Bronchopneumonia

Pneumonia- considerations

Non- resolving pneumonia:

Wrong antibiotic, lack of compliance, not-absorbing antibiotic, immunocommpromised, intrinsic airway problem (obstruction), not pneumonia => CT

Bacterial pneumonia usually resolves in 6 weeks with treatment (longer if elderly, COPD, ETOH)

Dehydration: hydration will enhance appearance of pneumonia

Neutropenia: increasing white count will enhance appearance of pneumonia

Pneumonia- Considerations

Mimics pneumonia:

Cancer: postobstructive pneumonia from lung CA,

bronchoalveolar, lung CA, pulmonary lymphoma…

Non-neoplastic- aspiration, hemorrhage, pulmonary edema,

sarcoidosis…

PCP pneumonia

HIV: CD4 < 200

Bilateral

symmetric

perihilar

opacities

(however has

variable

appearance)

Tuberculosis TB infection

Latent TB infection: Positive tuberculin skin test; no clinical, radiologic, or bacteriologic

evidence of disease

Active TB infection: Clinical, radiologic, or bacteriologic evidence of active disease

Primary TB

Initial infection of nonsensitized patients

Progressive primary TB in 5% of cases

Progressive lung involvement

Tissue necrosis & cavitation

Bronchogenic dissemination of infection

Post-primary TB

Reactivation of TB due to impaired immunity

Exogenous re-infection

Disseminated TB

Primary or post-primary TB

Related to immunosuppression

Latent TB

Primary TB

Miliary TB

Secondary TB

Sarcoidosis

Stage 0- normal CXR

Stage 1- bilateral symmetric hilar lymphadenopathy

Stage 2- stage 1 & reticulonodular parenchymal opacities

Stage 3- increased opacities but decreased lymphadenopathy

Stage 4- pulmonary fibrosis, bullae (usually in upper lobes)

Sarcoidosis- stage 0

Emphysema

Chronic obstruction

leading to destruction

of alveoli and

hyperinflation,

bullae, decreased

lung density,

decreased

vasculature,

flattened diaphragms

Asthma

Hyperinflated lungs

(>10 ribs on

inspiration),

peribronchial

cuffing (also seen in

chronic bronchitis,

bronchiectasis,

pulmonary edema &

cystic fibrosis)

Cavities

Abscess, fungal

pneumonia,

granulomatous

disease, tumors

(squamous cell

carcinoma)

“air crescent”

sign- fungal

ball/aspergilloma

Air Crescent sign

Pulmonary Embolism

80-90% with abnormal CXR

Findings: non-specific (subsegmental atelectasis, ill-defined

opacities)

Hamptom’s Hump: peripheral, pleural-base cone shaped

opacity from post-obstructive infarct of lung tissue

Westermarks’ sign: abrupt tapering of a vessel with focal

oligemia

Hamptom’s Hump

Westermark’s Sign

Lung Cancer

In 10% of heavy smokers (>35 pack years)

1. squamous cell carcinoma. 2. adenocarcinoma

92% of Lung CA with history of smoking

Bronchogenic carcinoma:

Adenocarcinoma 45%

Squamous cell carcinoma 35%

Small cell carcinoma 15%

Large cell carcinoma 1-5%

Lung Cancer

Nodules < 3cm; Mass > 3cm Malignant: large nodules, lobulated/spiculated

margins, older patient, enhances with iv contrast, cavitary lesion with wall thickness > 16mm (95% malignant)

Benign: calcification (diffuse, central, “popcorn”, laminar), very fast growth (double volume < 1mo), very slow growth (stable for > 2 yrs), smooth margins, cavitary lesion with wall thickness < 4mm (>95% benign)

Pathologic lymph nodes: > 1cm

Lung Cancer

Squamous cell CA: central mass with atelectasis or postobstructive pneumonia, cavitation (30%)

Adenocarcinoma- peripheral nodule/mass, pneumonia that fails to resolve

Bronchoalveolar CA- multiple nodules, chronic airspace consolidation or interstitial pattern

Small cell CA: extensive mediastinal lymphadenopathy without other findings or central mass, distant metastasis at diagnosis

Large cell CA: central or peripheral mass

Pulmonary metastasis: multiple, lung bases (perfusion), peripheral (90% outer third)

Pancoast tumor

Usually Squamous cell or adenocarcinoma

At lung apex with invasion causing horner’s syndrome (miosis, ptosis, anhydrosis) & atrophy of muscles ipsilaterally

Reverse S sign of Golden

Convex bulge in

medial aspect of

minor fissure in

patient with right

upper lobe

atelectasis from

obstructing

central mass

Lung

Metastasis

Bones

Ribs, Clavicles, Spine, Shoulders, Scapulae

Rib Fracture

Child abuse:

posterior rib fractures, calluses, multiple stages of healing

Child Abuse- rib fractures

Cardiac

Heart

Congestive Heart Failure

Cardiomegaly

Pulmonary Edema

Pericardial Effusion

Mediastinum

Anterior Mediastinum

Paraspinal bulge

Pneumomediastinum

Aorta

Cardiomegaly

Causes: pericardial disease, valvular heart disease,

cardiomyopathy, hypertension, congenital…

Cardiothoracic ratio

Heart size vs chest width:

25-50% nl, 50-60% ?, > 60% abnormal

Considerations: upright vs supine CXR, PA vs AP, inspiration

Cardiomegaly ?

Good vs Bad inspiration

Cardiomegaly

Cardiomegaly

Left Ventricular Heart failure

CXR relation to PCWP

15 mmHg- normal CXR

15-20 mmHg- pulmonary venous hypertension

cephalization (can look normal in chronic disease)

>20 mmHg- pulmonary edema

Blurring margins of central pulmonary vessels, Kerley lines,

thickening of bronchi walls

To be continued…

Pulmonary Edema

Non-cardiogenic Pulmonary Edema Findings: normal heart size, perihilar

opacification, rare air bronchograms

Pulmonary injury Patchy opacification (mostly alveolar injury), air

bronchograms, normal heart size/pulmonary vessels, rare kerley b lines or pleural effusions

Pulmonary Edema

Causes:

Increased hydrostatic pressure- LVH, mitral stenosis,

anomalous pulmonary return, high altittude disease)

Decreased plasma oncotic pressure- nephrotic syndrome

Impaired capillary integrity- infection, acid aspiration, toxic

inhalation

Pulmonary Edema

Increased hydrostatic pressure (ie CHF) Findings: Grade I- cephalization

Grade II- peribronchial cuffing, pleural effusions, kerley b lines

Grade III- alveolar opacification, air bronchograms

Grade I: Cephalization

Grade II peribronchial cuffing, pleural effusions, kerley b line

Kerley lines

A- multiple arcuate lines radiating from hila

B- multiple short horizontal linear densities perpendicular

to pleural space

C- cobweb mesh of linear opacities in middle portion of

lungs

Can also represent interstitial fibrosis, pulmonary

hemorrhage, lymphangitic spread of tumor

Kerley lines

Kerley B

Grade III alveolar opacification, air bronchograms

Pericardial Effusion

Causes: infection, immune reactions, trauma, neoplasm,

inflammation…

CXR

Frontal: Cardiomegaly

Lateral:

“oreo cookie” sign- vertical opaque stripe between anterior heart

border (epicardial fat) and pericardial fat

Follow-up with Echo, CT or MRI

“Oreo Cookie”…yum

Mediastinum

Anterior Mediastinum Four T’s

Thyroid mass

Thymoma

Teratoma

“Terrible Lymphoma”

Cervicothoracic sign: “neck” mass

Anterior mediastinum if lateral margins of mass above clavicles are blurred (four T’s)

Posterior mediastinum if lateral margins of mass above mediastinum are sharp (ie... Paraspinal bulge)

“Cervicothoracic Sign”

Thyroid Mass

“Cervicothoracic Sign”

Posterior Mediastinal Mass

Mediastinum Paraspinal Bulge:

90% neurogenic tumor:

neurofibromas,

neuroganglioneuromas

Traumatic spine fracture

with hematoma

Mediastinum Pneumomediastinum: Laceration of trachea, main stem bronchus or esophagus

Aortic Issues

The wide mediastinum:

Aortic laceration

Aortic aneurysm

Aortic dissection

Aortic Issues

Aortic Laceration

Usually from MVA

Findings: Wide mediastinum (>8cm at level of aortic arch),

blurred aortic arch, blood over apex of lung as a white

crescent (apical cap), hematoma pushing trachea right and

left main bronchus down, NGT pushed right

Aortic Laceration

Aortic Issues

Aortic Aneurysm fusiform/saccular & focal

Aortic Dissection Fusiform/normal, diffuse Debakey classification

I – ascending & descending aorta II- ascending aorta to origin of great vessels III- disttal to left sublacvian artery

Stanford classification A- involves ascending aorta (5% survive 1 year without surgery) B- spares ascending aorta (70% survive without surgery)

Tx: Surgery for I, II, A & Medical (BP control) for III, B

CXR signs: wide mediastinum, increased size of aorta, medial displacement of intimal aortic calcifications Further evaluation with CT, TEE, MRI, angio

Aneurysm & Dissection

aneurysm

dissection

Diaphragm & Pleural surfaces

Pneumothorax

Spontaneous

Tension

Pleural Effusions

Diaphragm

Rupture

Hiatal hernia

Pleural Mass

Pneumothorax

Spontaneous: Primary: associated with apical blebs

Secondary: to COPD, pulmonary fibrosis, langerhans cell histiocytosis, neoplasm…

Hospitalized patients: thoracentesis, mechanical ventilation, central lines

Tension: Cause: usually positive pressure mechanical ventilation or

penetrating chest trauma

Clinical signs: rapid hemodynamic/respiratiory deterioration, hyperresonant ipsilateral hemithorax, decreased breath sounds, contralateral displacement of trachea & cardiac apex

Treat first, CXR later

Tension Pneumothorax

Pneumothorax

CXR signs:

Upright CXR

End expiratory film

Decreased lung volume relatively increases ptx volume

Increased density of lung vs ptx

Sharp line of visceral pleura

Supine CXR

Hyperlucency of lung base, deep sulcus sign, double diaphragm

sign

Lateral decubitus CXR: ptx side up

Pneumothorax

“Deep Sulcus” Sign

Pleural Effusions

Plasma ultrafiltrate, empyema, hemothorax, urine, bile... Transudative vs exudative

Common causes: cardiogenic/noncardiogenic pulmonary edema, pneumonia, neoplasm, autoimmune disease

Upright CXR: blunt costophrenic angles >150-300 ml of fluid

Lateral decubitus CXR: Affected side down- layering of effusion Check for loculation

Supine CXR: Blunt costophrenic angle, loss of hemidiaphragm definition, general

increase in hemithorax density May obtain lateral decubitus CXR, cross table lateral, CT or U/S

Blunt Costophrenic angle

Layered Pleural Effusion

Subpulmonic Effusion

Effusion between lung & diaphragm

Signs: lateral displacement of diaphragm apex, no visible

bronchovasculature behind “pseudodiaphragm”,

increased distance between left diaphragm & gastric

bubble (nl < 2cm), posterior meniscus on upright lateral

CXR

Subpulmonic Effusion

Diaphragm Rupture Usually from trauma

Left side 9 of 10 times

Herniation of bowel

Hiatal Hernia

Pleural Mass Pleural vs Lung mass “Snow Ball” sign Round = in lung Flattened = surrounding tissue

Everything else

Tubes, Lines & Catheters

Endotracheal tube

NG tube

Central Venous Catheter

Swan-Ganz catheter

Why care?

Check for complications of tubes, lines and catheters

Avoid mistaking them for pathology

TLC placement

ET tube: 4 cm above carina

because flexion/extension may move tip up to 4 cm (~ level of clavicular head)

TLC placement

NG tube: Between esophageal-

gastric junction and pylours

Central venous catheter: Over shadow of SVC

between 1st rib/clavicle and right atrium (above R atrium to avoid arrythmias) Right Subclavian central line

TLC placement

Swan-Ganz catheter: Right or Left main

pulmonary artery or large lobar branch

TLC complications Device Complication Inappropriate position

Endotracheal tube Aspiration (parenchymal opacities),

pharyngeal perforation (subc

emphysema, pneumomediastinum)

Esophageal intubation, selective

mainstem bronchus intubation, too high,

balloon too big (> 2-3 cm)

Nasogastric tube Aspiration, intracranial perforation, ptx Intratracheal intubation,

intraesphophageal, intraduodenal

Chest tube Lung perforation (mediastinal opacity) Extrathoracic, apical (Horner’s syn)

Central Venous Catheter Ptx, bleeding (mediastinal, pleural), air

embolism

Extravascular, peripheral, intracardiac

Swan-Ganz catheter Ptx, bleeding, air embolism Proximal, distal (pulmonary infarction)

NGT gone wild

pneumothorax

What went wrong?

Right Mainstem Intubation

Abdominal Radiography

Acute Abdomen Series:

Upright CXR

Upright KUB

Supine KUB

Landmarks

Normal Kub

Directions

Free ABDO Free fluid

Air Outside bowel- free intraperitoneal air, retroperitoneal air,

branching air in liver, abcess, air in bowel wall

Inside bowel- dilated bowel, air fluid levels

Bowel wall thickening inflammation & ischemia

Densities bone, calcifications, other…

Organs outlines of liver, spleen, kidney & bladder

Anything Wrong?

Free Fluid

Supine KUB: free fluid if…

distance between colon and flank fat stripe greater than the

width of a pinky finger

Large amounts of free fluid will cause a diffuse increased

opacification in the abdomen

Lots of fluid- supine KUB

Now What?

Air outside

Why? Perforations!

Peptic ulcer disease, diverticulitis, colon ca, obstruction…

Normal after abdominal surgery- about 10 days for reabsorption

Upright CXR

Free air under diaphragm

Chilaiditi’s Syndrome: incorrect diagnosis of free air from large bowel between liver and diaphragm

Left Lateral Decubitus film: free air above liver

Upright CXR

Left Lateral Decubitus

Air Outside… again

Abdominal Film: Rigler’s sign: bowel wall outlined by air inside and outside

bowel Retroperitoneal Air: Perforation from parts of duodenum, ascending/descending colon

Air outline kidneys, iliopsoas muscle, abnormal air streaks extending into iliopsoas

Branching air in Liver: Pneumobilia: bile duct manipulation (sphincterotomy) or

emphysematous cholecystitis

Portal venous air (ominous): massive bowel infarction

Abscess: local collection of air not in bowel Abnormal bowel location, no haustra or plicae circulares, air in stable

location

Pneumatosis Intestinalis (air in bowel wall): bowel ischemia/infarct

Retroperitoneal Air

Pneumobilia

Pneumobilia Emphysematous Cholecystitis

Rigler’s Sign

Pneumatosis Intestinalis

Portal Vein Gas

Air- Inside

Small vs Large Bowel: Small bowel: central, plicae circulares

(circumferential)

Large bowel: framing, haustra (non-circumferential)

Air Fluid levels: line with air above and fluid below

Dilated bowel… size and loss of lines Small bowel > 3cm

Large bowel > 6 cm

Cecum > 9 cm

Air Inside- Nuts’n Bolts

Ileus: paralyzed bowel

Localized- inflammation

Generalized- drugs, surgery, pain

Bowel obstruction

Adhesions, hernia, bowel CA, intussusception,

ischemia, volvulus, Crohn’s, Meckel’s

diverticulum, gallstone ileus…

Proximal dilation, distal collapse

Complete vs partial: check for distal air (rectum)

ileus or obstruction?

ileus


Large Bowel

Obstruction


SBO

Air Inside- more Nuts’n Bolts

Volvulus

Sigmoid

More common

Coffeebean or inverted U shape dilation in lower abdomen

Cecal

Like a stomach bubble in middle of abdomen

Acute Pancreatitis

“Sentinel loop”: focal small bowel ileus in ULQ

“Colon cutoff sign”: distended transverse colon with no gas

distal to splenic flexure

Left pleural effusion

Sigmoid Volvulus

Acute Pancreatitis

Localized ileus

Bowel wall thickening

Sign of bowel inflammation or ischemia

Narrowed lumen, thickening folds, “thumb printing”,

loop separation

“thumbprinting”

Densities

Bone: vertebral column, pelvis

Appendicitis: Appendicolith: seen in 10% of appendicitis Other findings: RLQ ileus, blurred right psoas shadow, extraluminal soft-

tissue mass, pneumoperitoneum, scoliosis of lumbar spine- convex to left

Stones: Gallstones: RUQ Renal/Ureteric stones: 80-90% visible on plain abdominal film

Pancreatic Calcifications: chronic pancreatitis

Abdominal Aortic Aneurysm (AAA): calcified aorta > 3cm width

Uterine Fibroids, Phleboliths, Dermoids, foreign objects, lines & tubes…

Uterine fibroid

Cholelithiasis

Renal/Ureteric Stones

Foreign Object

Organs

Check for abnormal shape and size

Liver

Spleen

Kidneys

Bladder

Hepatospenomegaly

Splenomegaly

Remember

CXR

ABCDE

Air

Bones

Cardiac

Diaphragm & pleura

Everything Else

Abdominal Films

Free ABDO

Free air

Air inside/outside

Bowel wall thickening

Densities

Organs

Credits

Douglas S. Katz, MD, et al. Radiology Secrets.

Hanley and Belfus, Inc. Philidelphia, PA, 1998

Hague Ouellette, MD, et al. Clinical Radiology

made ridiculously simple. Medmaster Inc.

Miami, FL, 2000.

Ryan W Davis, et al. Blueprints in Radiology.

Blackwell Publishing, Inc. Mass, CT, 2003.

And many thanks to the internet for images

Chest X-rays & Abdominal Plain...

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