Emergency Radiology in Surgery

Dr. Upendra BhardwajR.S.O. Surgery

G.R.M.C.

GuideProf. Dr. Achal Gupta

(M.S. D.N.B.)G.R.M.C. Gwalior

Head of Deptt Prof. Dr. B.R. Shrivastava

(M.S.,M.C.H., P.H.D.)G.R.M.C. Gwalior

CoguideDr. Ashish Gupta(M.S.)

ROENTGENOGRAM

• Image of internal body orgen over photographic plate with the help of X-rays.

Normal Chest X-ray• View• Exposure• Centralization• Skeletal structure • Lung fields including blood vessels and

pleura• Cardiovascular silhouette • Mediastinum • Costophrenic and cardiophrenic angle • Diaphragm • Soft tissue abnormalities

Normal Chest X-ray described as• This is PA view of chest x-ray with normal

exposure proper centering without any appearent bony abnormality. The lung fields are clear with normal bronchovascular marking cardiovascular silhouette is with in normal limit with normal cardiothorcic ratio, mediastinum costophrenic, cardiophrenic angles dome of the diaphragm and soft tissue show no abnormality.

Pleural effusion• Triangular homogeneous opacity with

a curved upper border which is concave medial and upward extend to ward axilla

• Costophrenic angle is obliterated. • Trachea and cardiac shadow shifted

slightly to opposite side.

Pneumothorax • Increased translucency on

right side of the chest.• Absent of lung marking • Sharp homogenous opacity

near the hilum which indicate the collapsed lung.

• Trachea shifted to opposite side.

• Dome of diaphragm flattened.

Hydropneumothorax • Horizontal fluid level• Increased transluncency

above the horizontal fluid level which is lacking in lung markings (pneumo component) and homogenous opacity is below the horizontal fluid level (hydro component).

• Trachea shifted to opposite side.

• Shifting dullness

Normal plain abdominal X-ray

What to Examine

• Bone • Solid organ• Gas pattern• Air fluid level• Soft tissue masses• Calcifications• Foreign body

Gas pattern

Normal Gas Pattern

*Stomach– Always

*Small Bowel– Two or three loops of non-distended

bowel

*Large Bowel– In rectum or sigmoid – almost always

Gas in stomach

Gas in a few loops of small bowel

Gas in rectum or sigmoid

Normal Gas Pattern

Free AirCauses

• Rupture of a hollow viscus– Perforated ulcer– Perforated diverticulitis– Perforated carcinoma– Trauma

• Post-op 5–7 days• Instrumentation

Abnormal Gas pattern

Air in gastric wall

Abnormal Gas Pattern

Air In I.H.B.R.

Abnormal Gas Pattern

Air in portal Vein

Signs Of Pneumoperitonium

Gas under diaphragm

Signs Of Pneumoperitonium

Falciform ligament sign(Silver sign)

Signs Of Pneumoperitonium

Double wall sign

Differential Diagnosis of Pneumoperitonium

• Linear atelectic band

Differential Diagnosis of Pneumoperitonium

• Chilaiditis syndrome

Differential Diagnosis of Pneumoperitonium

• Meteorism

Differential Diagnosis of Pneumoperitonium

• Subphranic abscess

Differential Diagnosis of Pneumoperitonium

• Lipoperitonium

Differential Diagnosis of Pneumoperitonium

• Distended gastric fundus

AIR FLUID LEVEL

Normal Fluid Levels

*Stomach– Always (except supine

film)

*Small Bowel– Two or three levels

possible

*Large Bowel– None normally

Erect Abdomen

Always air/fluid level in stomach

A few air/fluid levels in small bowel

Large vs. Small Bowel

*Large Bowel– Peripheral– Haustral markings don't

extend from wall to wall*Small Bowel

-Central-Valvulae extend across lumen

• One or two persistently dilated loops of large or small bowel

• Gas in rectum or sigmoid

Localized IleusKey Features

Sentinel Loops

Supine Prone

PancreatitisUlcer

Diverticulitis

Cholecystitis

Appendicitis

UlcerUreteral calculus

Sentinel Loops

• Gas in dilated small bowel and large bowel to rectum

• Long air-fluid levels

Generalized IleusKey Features

Generalized Adynamic Ileus

Supine Erect

Mechanical SBOKey Features

• Dilated small bowel• Fighting loops• Little gas in colon, especially

rectum

SBO

Mechanical SBOCauses

• Adhesions• Hernia• Volvulus• Gallstone ileus• Intussusception

*Cause may be visible on plain film

Mechanical LBOKey Features

• Dilated colon to point of obstruction

• Little or no air in rectum/sigmoid• Little or no gas in small bowel, if…

– Ileocecal valve remains competent

LBO

Supine Prone

Mechanical LBOCauses

• Tumor• Volvulus• Hernia• Diverticulitis• Intussusception

Volvulus • Sigmoid volvulus - Coffee beam appearance

Volvulus • Cecal volvulus

INTUSSUSCEPTION

Intussusception Target sign

Cresent sign

Intussusception Coiled spring appearance

Soft Tissue Masses

Soft Tissue Masses

• Hepatosplenomegaly– Plain films poor for judging liver

size• Tumor or cyst

– Bowel displacement *decrease of gas *Extrinsic compression of bowel

Splenomegaly

Myomatous Uterus

Bowel displacement

decrease of gas

Bladder Outlet Obstruction – pre- and post- cath

Hours later

Right Renal Cyst

Extrinsic compression of bowel

Calcification

Calcificationpancreas

kidney

Gall bladder

Suprarenal glands

Gall bladder

Pancreatic mass

Seminal vesicles

prostate

Fibroid uterus

Ureteric calculi

Calcified faecolith

Foreign body

Foreign Bodies

Objects that may be seen include ingested and rectal foreign bodies, such as coins, dress buttons and jewelry. Other objects may have been operatively placed for example an aortic stent, an inferior vena cava filter or a suprapubic urinary catheter. Sterilization clips and an intra-uterine device are common findings in women.

Sterilisation and Surgical Clips Foreign body per rectum

Coin in esophagus

Post op. retained sponge

SONOGRAM

ARTERYS AND VEINS

NERVES

EPIGASTRIUM VIEW

PERICARDIAL EFFUSION

RT HYPOCHONDRIUM VIEW

FLUID IN MORISON’S POUCH

LT HYPOCHONDRIAL VIEW

SPLENIC FRACTURE

HYPOGASTRIUM VIEW

FLUID IN POUCH OF DOUGLAS