Emergency radiology - Postgraduate Medical Journal › content › postgradmedj › 43 › 503 ›...

Postgrad. med. J. (September 1967) 43, 558-567.

Emergency radiologyI. Surgical emergencies

OSCAR CRAIGF.R.C.S.I., F.F.R.

Consultant fiSt Mary's Hospital, London, W.2, and

THE CASUALTY OFFICER is commonly faced withthe problem of requesting X-rays and makingan initial interpretation in emergency cases. Asmost of these requests will be for plain films, theemphasis of this paper will be directed to thecorrect films to be taken and their interpretation.Occasionally contrast examinations are necessaryand some points regarding emergency intravenouspyelograms and emergency barium or gastro-grafin examinations will be touched upon.

In cases of acute venous obstruction or aorticand peripheral embolization the contrast examina-tion will be performed by the radiologist and theinterpretation is comparatively simple. These caseswill not be discussed. Fractures have been dealtwith elsewhere and will also be omitted. Theremainder of the common emergencies will bedivided into surgical and medical groups, althoughit is appreciated that many conditions such ashydropneumothorax may fall into either section.This first paper will deal with some commonsurgical emergencies.

Swallowed foreign bodyThe most commonly impacted foreign body is

a fish or meat bone. The accurate localizationradiologically depends on its density. Many haveinsufficient density to be recognized readily andthis applies especially when they are impactedbelow the thoracic inlet. To detect a pharyngealor upper oesophageal foreign body, good qualityantero-posterior and lateral films of the neckshould be taken. When examining these it isimportant to appreciate the appearance of thenormal hyoid bone, the thyroid, cricoid and laryn-geal cartilages. When possible a normal film shouldbe available for comparison.

Fig. 1 shows a small fish bone which washidden by the hyoid bone and only visible onmoving the tongue.Dense foreign bodies are usually readily seen

in the pharynx. Even though a foreign body is

Radiologist,Bolingbroke Hospital, London, S.W.1 1

FIG. 1. Lateral of neck with head more extended;fish bone visible.

not identified, it is important to look for signsof complication such as: (1) air in the prever-tebral space, indicating perforation (Fig. 2); (2)increase in width of the prevertebral space, some-times with anterior displacement of the larynxor trachea (Fig. 3). This indicates either a diffusecellulitis or abscess formation.

If there is still doubt about the presence of aforeign body then a contrast examination may benecessary. A barium swallow with micropaqueis not likely to localize a small foreign bodysuch as a fish bone. Pledgets of cotton woolsoaked in barium may be given in the hope thatthey are held up by the sharp edge of the im-pacted bone.

In the case of an impacted non-opaque foreignbody such as a lump of meat, the routine micro-paque swallow will usually be successful anddemonstrate a filling defect. It is important that

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Emergency radiology

after removal of this type of foreign body thebarium examination should be repeated to exclude Xany underlying cause such as a benign or malig-nant stricture. However oesophagoscopic examina-tion at the time of removal of the impaction maybe conclusive.

It is not uncommon for a small mucosal tearin the pharynx to cause dysphagia for somedays even though the foreign body has passedthrough the alimentary tract quite successfully. X

Solid radiopaque foreign bodies such as buttons,coins, hairgrips, etc., which pass into the stomachcan be followed radiologically by plain antero-posterior abdominal films at intervals. Havingpassed the stomach they rarely give rise to anytrouble. Occasionally an open pin or a hair gripmay become inpacted and require surgical re-moval.

Inhaled foreign body ~..There is little difficulty in localizing dense _

metallic foreign bodies if films are taken in both - .the antero-posterior and lateral planes. Moretrouble is met with in localizing non-opaqueforeign bodies such as peanuts. The followingfilms will often be required: -. .......~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~... .. ..... ...........

.~~~~~~..................;-..-....-;.

FIG. 3. Retropharyngeal mass following the per-foration of a foreign body.

1. Postero-anterior of chest.2. Lateral.3. Films in inspiration and expiration.4. Rarely, oblique views or over-penetrated

postero-anterior views.The following changes may be noted;

(1) Collapse of a lobe or lung. An area ofconsolidation may be seen. The lung vascularpattern may be altered secondary to collapse and

**R;_ _ ^ °e affected side._s .::. : ..........................thrma e hfto hemdasiu t h(2) Patchy inflammatory changes may occur

distal to the obstruction.(3) Obstructive emphysema may occur. This

gives rise to 'over-inflation' of one lung withhypertranslucency. The mediastinum may be dis-placed to the opposite side and the diaphragmmay be flattened. Screening, or films in bothinspiration and expiration may demonstrate the

_'swinging mediastinum'. It moves across towardsFIG. 2. Air in the prevertebral space after pharyngeal the central area on inspiration and to the un-perforation. affected side on expiration (Figs. 4 and 5).

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All of these signs may not be present. Themost common sign is a hydropneumothorax, butthis together with the history is often diagnostic.The site of the tear may be demonstrated by a

gastrografin swallow. This should be performedw1 ( supine and care taken to posture the patient-- I Xadequately. It is better, however, to inject small

quantities of gastrografin at different levels in theeeioesophagus through an oesophageal tube. This

can be done under screen control and obliquespot films can be taken.

Chest traumaThe correct films to request when rib fractures

are suspected are a postero-anterior of the chestand the appropriate oblique views.

In any major chest injury the fractures maybe so severe as to cause a 'floating sternum' orflail chest. No matter how mild the injury acareful search for the following should be made:

FIG. 4. Inspiration with shift of the heart to the left. 1. Pneumothorax.

2. Haemopneumothorax.3. Surgical emphysema.4. Pneumomediastinum.Surgical emphysema may indicate rupture of

the trachea or main bronchus. A pericardialeffusion may also occur. This alters the contourof the heart, and causes 'filling in' of the normalpulmonary bay and straightening of the left heart

* w ei border. The heart may become globular in shapewith sharp angulation at the cardio-phrenic angles.Occasionally closed chest trauma results in 'butter-fly' perihilar shadows similar to those of pul-monary oedema and due to intra-alveolar

;F

FIG. 5. Expiration with return of the heart to a centralposition.

Ruptured oesophagus (Fig. 6)When this is suspected, postero-anterior and

lateral films of the chest should be taken. Thefollowing signs may be found:

1. Pleural effusion, most often left-sided butsometimes bilateral.

2. Pneumothorax or hydropneumothorax.Films in expiration more readily show apneumothorax.

3. Pneumomediastinum. This gives rise to afine translucent zone around the heart andgreat vessels. FIG. 6. P.A. chest showing left hydropneumothoraxand collapse of the left lower zone following rupture of

4. Surgical emphysema in the neck. the oesophagus.

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Emergency radiology

haemorrhage. Localized pulmonary haemorrhagemay cause a rounded lung opacity similar to aperipheral carcinoma or a secondary deposit.Follow-up films demonstrate a slow resolution.

Ruptured diaphragmThis may follow concussion of the thorax or

abdomen or both together. The left hemidia-phragm in its posterior part is the area mostoften injured. The stomach is the most frequentorgan to herniate into the thorax. This mayproduce a confusing X-ray as the contour of thefundus can be mistaken for an elevated dome ofthe diaphragm.When a fluid level is present in the stomach

it is not unusual to mistake the appearance fora hydropneumothorax. Either gastric aspirationor a gastrografin swallow will settle the diagnosis.It is possible to have two fluid levels, one in theherniated stomach, and a second in a hydro-pneumothorax. In these cases it is important tohave erect films and both posteroanterior andlateral views. The lateral decubitus antero-posterior (A.P.) view may be substituted for theerect film when necessary. For this the patientlies on one or other side, and an A.P. view istaken with the X-ray beam horizontal.

Other organs may herniate, such as the spleenor large bowel. If gas is present in the large bowelthen its haustral markings will identify it andprovide a diagnosis.On the right side the liver may herniate.Cases of abdominal and chest trauma are

increasing daily and it is the object of the X-rayexamination to demonstrate the extent and natureof these injuries. In the abdomen the liver, kid-neys and spleen are most prone to injury. Ruptureof the stomach, small intestine, caecum andurinary bladder are also frequent injuries. It isimportant to search the X-ray for signs of:(1) free gas, (2) free fluid, (3) retroperitonealbleeding, which may cause large soft-tissue opaci-ties with displacement of normal structures; and(4) meteorism.

Later there may be signs of peritonitis withthe picture of a paralytic ileus. X-rays of thespine, ribs and pelvis may be required separatelywhere associated bony injury is suspected.The acute abdomenEvery acute abdomen justifies two films, one

supine and one erect. If the patient is too ill tostand for the erect film then the lateral decubitusfilm with the antero-posterior projection shouldbe taken.Perforation of a hollow viscusThe most common perforations result from

peptic ulceration of the stomach or duodenal

cap. However, an inflamed diverticulum orappendix may perforate. Cases of acute perfora-tion of a large bowel carcinoma have been des-cribed. Closed abdominal injury may also resultin perforation of stomach, duodenum, or caecum.The most important film in these cases is the

erect projection showing the diaphragmatic areas.The film is examined for the translucent line offree gas under each dome. Where the X-ray doesnot reveal free gas, but the clinical picture ishighly suggestive of perforation, then a lateralfilm of the diaphragmatic areas should be re-quested. This will show smaller quantities ofgas that may not have been visible on the routineview. Hepatic interposition of the transverse colonmay occasionally suggest free air but the presenceof haustral markings will identify large bowel. Ifthe haustral markings are not obvious then alateral decubitus film with the right side raised ishelpful. Free gas will form a layer between theabdominal wall and the liver.A sign is sometimes seen on the supine film

usually indicating a small duodenal perforation.This consists of a small crescent-shaped gasshadow beneath the lower edge of the liver.

In the latter stages of perforation paralyticileus may occur and add to the radiologicalpicture. Very rarely the soft-tissue shadow of anabdominal mass may be seen, e.g. a diverticularabscess or appendix mass. Contrast examinationsdo not have an established place in the investiga-tion of perforations from peptic ulceration.

Intestinal obstructionThe salient features are gas-distended intestinal

coils with fluid levels and absence of gas in thebowel distal to the obstruction. Both erect andsupine films are necessary. The lateral decubitusfilm already described may replace the erect viewin patients too ill to stand. The supine film enablesthe extent of gaseous stasis to be judged and theareas of absence of bowel gas are noted. Thepattern of the bowel involved is noted. Thejejunum has a 'coiled spring' appearance. Theileum may be structureless. The large bowel hasa haustral pattern.

Jejunum lleum CoLon

(1 2)

Jejunal coils are usually situated centrally andhigh in the abdomen. Ileal coils are central andlow. The large bowel coils are distributed aroundthe flanks.

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By observing the pattern of the coils involved,their position and the areas of stasis, the diag-nosis both of the obstruction and of its site canbe judged.

Figs. 7 and 8 show dilated jejunum and ileumdue to an ileal obstruction. Figs. 9 and 10 showthe appearance of a large-bowel obstruction.The presence of fluid levels does not invariably

indicate a bowel obstruction. Especially in child-ren, multiple fluid levels may occur in gastro-enteritis. Diverticulosis of the small bowel maygive rise to multiple short fluid levels. A waterenema may result in large bowel fluid levels, andshould never be given before the radiologicalexamination.When an obstruction is diagnosed a careful

search should be made for any possible cause.The soft-tissue density of a neoplastic mass or adiverticular abscess may be seen. Rarely the gaspattern may outline a stricture.Examine the liver area for signs of 'liver gas'.

This may be either in the portal system or biliarytree. When in the biliary tree the branching hepaticducts may be recognized (Fig. 11). Portal gas,unlike biliary gas, may extend right to the peri-phery of the liver. Gas in the portal system indi-cates bowel gangrene. Gas in the biliary tree maybe due to a fistula and associated with intestinalobstruction may indicate a 'gall-stone ileus'. Thestone usually lodges in the terminal ileum.

Contrast examination has no part to play incases of acute intestinal obstruction. In subacutesmall-bowel obstructions gastrografin or evenbarium meal examinations may be helpful. Insubacute large-bowel obstruction a barium enemamay be performed.

Parlytc ileusThis may be post-operative or result from

intra-abdominal sepsis either local or generalized.Generalized paralytic ileus involves both the largeand small bowel with distension and fluid levels.It must be differentiated from a mechanical ob-struction. In paralytic ileus there is often no'cut-off' to the bowel involvement and whenascitic fluid is present the loops of bowel areseparated by a soft tissue shadow that is wider andmore dense than normally. There may be loss ofthe normal translucent flank line on one or bothsides.A gastrografin examination may be misleading

as the contrast may diffuse through the bowel inthe absence of peristalsis.

Volvulus of the sigmoldThis presents as a large gas-distended loop

rising out of the pelvis and occupying most of the

abdomen. Fluid levels may be present in the loop.The appearance is normally that of an invertedU and the medial limbs of the loop can betraced downwards to the point of torsion.

Volvulus of the caecumThis can present similar appearances and at

times the differentiation is difficult. Fluid levelsare present in the loops or, if there is an axialtorsion, only one fluid level in the caecum. Animportant sign is the presence of distended small-bowel loops which are usually absent in sigmoidvolvulus. The loop of a caecal volvulus is usuallyopen medially and the appearances resemble akidney with the open end representing the kidneypelvis.

Acute appendicitisIt is usually only in doubtful cases that radio-

logical examination is requested. Erect and supinefilms of the abdomen should be taken. The follow-ing plain film signs may be present:

(1) Local ileus with stasis of gas and fluidlevels in neighbouring coils of ileum. Moreextensive changes due to paralytic ileus may beseen when peritonitis occurs.

(2) A calcified faecolith may be detected freein the abdomen, in the appendix, or in a local

FIG. 7. Supine film of abdomen. Gas-distended bowelshowing the 'coiled spring' appearance of jejunal loopsand the structureless appearance of ileal loops.

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Emergency radiology 563

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FIG. 8. Erect film of abdomen. Multiple fluid levels inthe jejunal and ileal coils. A case of low ilealobstruction.

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FIG. 9. Supine film showing predominantly large boweldistension.

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FIG. 10. Erect film. Multiple fluid levels in the largebowel and a few in the small bowel. A case of large bowelobstruction.

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FIG. 11. Gas in the biliary tree.



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abscess. Calcified faecoliths are more commonthan is appreciated and up to 10% of acuteappendices contain one. When a calcified faecolithis found in the presence of clinical appendicitis,it indicates an obstructive element.

(3) Loss of the psoas outline. There may be ascoliosis.

(4) A soft-tissue opacity due to an appendixabscess.

Fig. 12(a) shows a calcified faecolith and afluid level in the transverse colon. The combina-tion of a calcified faecolith much higher thanusual and the local ileus in the transverse colon,suggested a retrocaecal subhepatic appendicitis.This was confirmed at operation. Fig. 12(b) isan X-ray of the faecolith taken after its removal.

Subphrenic abscessPatients with subphrenic abscess may occa-

sionally be admitted with the diagnosis of anacute abdomen or lobar pneumonia. The sub-phrenic abscess may lie anteriorly or posteriorlyon the right or left side.Where subphrenic inflammation is suspected

erect films in both the antero-posterior and lateralplanes should be taken.

FIG. 12. (a) Erect film showing calcified faecolith andfluid in the transverse colon due to subhepatic appen-dicitis. (b) The calcified faecolith X-rayed afterremoval.

Fluoroscopy is often helpful and this may showelevation of one dome of the diaphragm withdiminished movement.The films may show:1. An elevated hemidiaphragm.2. Displacement of liver or stomach.3. A gas and fluid level.4. Pulmonary collapse and consolidation at

the adjoining lung base.5. Pleural effusion.On the left side the gas and fluid level may

be mistaken for the stomach. Contrast examina-tion of the stomach will differentiate. There maybe confusion with free gas under the diaphragmbut unlike gas in an abscess this moves freely onchanging posture.A gas-filled abdominal abscess other than a

subphrenic collection is more uncommon.

Abdominal calcificationsCalcified costal cartilages and calcified lymph

nodes should not be mistaken for visceral cal-cification. The most common calcified opacitiesassociated with an acute emergency are in thebiliary tract or the renal tract. Curvilinear calci-fication may be seen in the wall of an abdominalaneurysm and lying to the left of the spine.

Biliary tractOnly about 30% of gall-stones are radiopaque.

They are usually found in the right hypochron-drium, but may rarely be in the right iliac fossawhen there is gall-bladder ptosis or distension.For accurate locali7ation prone, oblique andlateral films should be taken. Cholesterol stonesare usually single and non-opaque. The inflam-matory mixed stones are usually multiple andcontain calcium. They may have a central trans-lucency. They are frequently faceted. One typeof gall-stones is shown in Fig. 13.A search should be made along the course of

the common bile duct in cases of biliary colic.Acute cholecystitis may show the following

signs on the plain films:(1) A soft tissue mass in the right hypochon-

drium. Empyema of the gall-bladder may producequite a dense opacity.

(2) Stones in the gall-bladder or in Hart-mann's pouch.

(3) Local ileus in the hepatic flexure or trans-verse colon.

Biliary sludge or limy bile may produce a denseopacity in the right hypochondrium (Fig. 14).

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FIG. 13. Gallstones.

FIG. 14. Biliary sludge plain film.

In emphysematous cholecystitis gas may beseen in the lumen or in the wall of the gall-bladder.Gas in the biliary tree may result from: (1) the

recent passage of a stone, (2) operative dilatationof the ampulla or a short circuit operation, (3)fistula formation due to stone, duodenal ulceror neoplasm, and (4) gas-forming organisms inthe gall-bladder.

Acute pancreatitisThere are three main types of acute pancrea-

titis.1. Acute haemorrhagic necrosis.2. Gangrenous pancreatitis.3. Suppurative pancreatitis often with abscess

formation.Erect and supine plain films are taken. The

following X-ray signs may be present:(1) Distension of the duodenal loop with fluid

levels present.(2) An 'inverted 3' may rarely be seen on the

plain films (Epsilon sign). This is demonstratedbest in prone films.

(3) Retention of gas and fluid in neighbouringloops of large and small bowel. Local ileus mayproduce a sharp 'cut-off' in the gas pattern ofthe transverse colon.

(4) Gas in the soft tissues behind the stomachdue to gas-forming organisms.

(5) Gall-stones may be present.(6) Pancreatic calculi may rarely be seen.(7) A soft tissue opacity due to abscess forma-

tion may be seen and may displace neighbouringorgans.

In the less acute phase a barium examinationmay show some of these signs, namely wideningof the duodenal loop, distortion and rigidity ofthe duodenal mucosa, an 'inverted 3' sign. Theremay be stasis of barium in the upper jejunalcoils for a prolonged period, and the deficiencypattern may also be seen. An abscess may pro-duce distortion of the stomach very similar tothat produced by a pancreatic cyst.

Renal emergenciesRenal colic is the most common renal emer-

gency. Approximately 90% of renal calculi areradio-opaque. The stone may be in the kidney oralong the line of the ureter to the bladder. It mayoverlie one of the lumbar transverse processes orthe sacral ala and not be readily seen. Therelationship of renal calculi to the kidney canbe seen by films on both inspiration and expira-tion and on the right side a lateral film will dis-tinguish them from gall-stones. In the pelvisphleboliths are recognized by their smooth roundoutline and their central translucency.An emergency intravenous pyelogram is justi-

fied in many doubtful cases of renal colic. Itis not uncommon to find absence of excretion ofdye on the affected side. Delayed films are takenup to 24 hr and these usually demonstrate anephrogram (Fig. 15) on the affected side andcontrast may fill the pelvis and pass down theureter to the site of the obstruction (Fig. 16).

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566 Oscar Craig

_ o < ^ ~~~~~~~~~~~~~~~. .... ......-:--°.:. -'.-.......

Xp:':':'i':::::i-::::......... .. ... .. .. :.

*~~~~~~~~~~~~~~~~~~~~~~.._ ,g:.,...................;. :.:.:.

.; ................. . ... ...... . :::::-Bo~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.' : .: . :. .: .: .. ;. :::..:::::~~~~~~~~~~~~~~~~~~~~~. '. ::. . .. .. .. ....

:.: ... .... .... : .::..:........... .....: .. .... ... ..... .. ...">:'::::.: ::.:::::.:.::: :.:::R...... .........::. ;.:.:. .. .... .: .:. .: :.:....... ........... ..

ge.. ...... -.:::.::. :.:........ .. .. ..

FIG. 15. Nephrogram on the right.

Rarely there may be extravasation of contrastmedium from the renal pelvis into the perirenalor subcapsular tissues.

Renal traumaInjury to the kidney may vary from a contu-

sion up to a complete tear or transsection. Ruptureof the kidney may be subcapsular, parenchymalor pelvic. Bleeding may occur at any of these sites.The plain film changes may be:(1) A soft-tissue mass in the renal area. The

clear zone around the kidney may be obliterated.The opacity may be diffuse or conform to theoutline of the kidney.

(2) Large haematomata may result in loss ofthe psoas outline, and there may be a scoliosisconvex to the opposite side.

(3) Local meteorism may occur.In all cases of renal trauma a search should

be made for bony injury such as rib or pelvicfractures. Other associated visceral injuries, suchas splenic rupture or intestinal perforation, shouldbe considered.

Following the diagnosis of renal trauma it ismandatory to perform an intravenous pyelogram.This enables an assessment to be made of thetype and degree of the injury and also checkson the presence and function of the oppositekidney.

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FIG. 16. The ureter is dilated down to the level of acalculus in the pelvis.

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FIG. 17. Extravasation of contrast medium around thekidney after an intravenous pyelogram.



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Emergency radiology 567

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FIG. 18. Small compressed left kidney followingtrauma and pericapsular bleeding.

Depending on the type of injury the followingmay be found:

(1) Extravasation of contrast from the renalcollecting system into the soft tissues (Fig. 17).

(2) Filling defects in the pelvis due to bloodclots.

(3) Distortion of the calyces and parenchymalspread of contrast at the site of a tear.

(4) A space-occupying lesion in the kidneyradiologically similar to a tumour and due tohaematoma formation.

(5) Subcapsular contrast extravasation.Fig. 18 shows an interesting case of left renal

trauma where the collecting system of the kidneywas much smaller than that on the other side.

It seemed likely that this was due to sub-

re : : :~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.::.. : :: :;.:. .. .... o:.ic;.i.

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FIG. 19. Return of left kidney to normal size after 2months.

capsular bleeding and renal compression, whichmay also have reduced the blood supply.A follow-up contrast examination 2 months

later (Fig. 19) showed a return of the renal sizeand pelvi-calycine filling to normal.

SummarySome common surgical emergencies are dis-

cussed. The appropriate plain films, contrastexaminations and their interpretation in each caseare described.

AcknowledgmentsI wish to thank Dr P. Cardew and the staff of the

Photographic Department, St Mary's Hospital MedicalSchool, for their great help in producing the prints of theX-rays.



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