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diagonostic radiology

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Information about diagonostic radiology
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Published on July 18, 2010

Author: ishfaq

Source: authorstream.com

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Diagnostic investigations : Diagnostic investigations Dr Muhammad Ishfaq Surgical C, Khyber teaching hospital Peshawar, Pakistan 2009 X-rays : X-rays Abdominal Abdominal X-Ray Projections: : Abdominal X-Ray Projections: Supine 99% Erect Lateral decubitus. Knowledge of the anatomy of the abdomen allows localization of the abnormalities observed on the AXR. Abdominal X ray : Abdominal X ray Only five main densities are seen, four of which are natural: Black for gas, White for calcified structures, Grey representing a host of soft tissue with a Darker grey for fat (as it absorbs slightly fewer x rays). Bright white , metallic objects are seen as an intense bright white Anatomy on the Abdominal X-Ray: : Anatomy on the Abdominal X-Ray: Abdominal X-ray : Abdominal X-ray ‘BLACK BITS’ Intra-luminal gas can be normal. Extra-luminal gas is abnormal. However, intra-luminal gas can be abnormal if it is in the wrong place or if too much is seen. The maximum normal diameter of the large bowel is 55mm. Small bowel should be no more than 35mm in diameter. Abdominal X-ray : Abdominal X-ray Intra-luminal gas: The natural presence of gas within the bowel allows assessment of caliber - although the amount varies between individuals. The caecum is not said to be dilated unless wider than 80mm. Large and small bowel may be distinguished Abdominal X -ray : Abdominal X -ray The haustra of the large bowel extend only a third of the way across the bowel from each side, whereas the valvulae conniventes of the small bowel tranverse the complete distance. Intra-luminal gas (continued): It is usual to see small volumes of gas throughout the GI tract and the absence in one region may in itself represent pathology. For example, if gas is seen to the level of the splenic flexure and nothing is seen beyond this, a site of the obstruction at this site – a ‘cut off’ point is noted. Intraluminal gas : Intraluminal gas Intra-luminal Gas: Low Small Bowel Obstruction Extraluminal gas : Extraluminal gas Causes of Extra-luminal gas: 1-Post Abdominal Surgery/ERCP 2-Perforation of viscus (eg. bowel, stomach) 3-Gallstone ileus 4-Cholangitis (infection with gas forming organisms) 5-Abscess Abdominal X-ray : Abdominal X-ray ‘WHITE BITS’ = Calcification Calcification can be broadly divided into 3 types: (1) Calcium that is an abnormal structure - eg. gallstones and renal calculi (2) Calcium that is within a normal structure, but represents pathology - eg. nephrocalcinosis, (3) Calcium that is within a normal structure, but is harmless - eg. lymph node calcification. Bones are normal ‘white’ structures. On the AXR they comprise mainly those of the thoraco-lumbar spine and pelvis. Findings are largely incidental as direct bone pathology would be investigated with specific views. Abdominal X-ray : Abdominal X-ray AXR : AXR ‘GREY BITS’ = Soft Tissues The kidneys, spleen, liver and bladder (if filled) can be seen in addition to psoas muscle shadows and abdominal fat. Rarely would action be taken on the basis of this imaging alone. AXR : AXR ‘BRIGHT WHITE BITS’ = Foreign Bodies 1-Ingested and rectal foreign bodies, 2-Items in the path of the x-ray beam such as belt buckles, dress buttons and jewelry. 3-Aortic stent, an inferior vena cava filter or a suprapubic urinary catheter. Sterilization clips and an intra-uterine device are common findings in women. Slide 15: This 67 year-old women presented to the surgical ward with a distended abdomen and vomiting. Case 2: : Case 2: This 71 year-old gentleman visits his GP complaining of blood in his urine. He has had a number of UTI’s in recent years. Case 3: : Case 3: This patient was admitted with poor renal function. :  Ceacal volvulus : Ceacal volvulus Sigmoid volvulus : Sigmoid volvulus Larg gut obstruction : Larg gut obstruction X ray KUB : X ray KUB A kidney, ureter, and bladder (KUB) x-ray study is an abdominal x ray. Despite its name, KUB does not show the ureters and only sometimes shows the kidneys and bladder and, even then, with uncertainty. BARIUM CONTRAST STUDIES : BARIUM CONTRAST STUDIES Both barium swallows and barium meals , barium follow through are investigations of the upper gastrointestinal tract which use a contrast substance called barium which shows up on X-ray series of X-rays are taken to allow the doctor to identify areas of abnormality such as tumors, inflammation or ulcers. BARIUM STUDIES : BARIUM STUDIES Barium swallow (esophagus) Barium meal : Barium meal barium meals (stomach and duodenum) BARIUM FOLLOW THROUGH : BARIUM FOLLOW THROUGH BARIUM ENEMA : BARIUM ENEMA A barium enema procedure inserts a radio-opaque contrast material (barium sulfate) into the rectum. This is a chalky mixture that can be visulaised with X-ray machinery and allows investigation of the inner surface of the large intestine (also called the colon). Barium enema is a common diagnostic investigation that provides structural information about the colon DOUBLE CONTRAST : DOUBLE CONTRAST barium is combined with a fizzy mixture that produces gas in the bowel. This is called a double contrast study. The gas expands the stomach and intestines and helps push the barium against the wall. This allows more detail to be visualised. MRCP : MRCP Visualize the biliary and pancreatic ducts in a non-invasive manner MRCP is purely diagnostic An important advantage of MRCP is that cross-sectional images can be obtained, displaying not only the ductal system but also surrounding parenchyma; this allows direct visualizations of and other diseases. ERCP : ERCP Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. Slide 31: Diagnostic Obstructive jaundice - This may be due to several causes Chronic pancreatitis - a now controversial indication Gallstones with dilated bile ducts on ultrasonography Bile duct tumors Suspected injury to bile ducts either as a result of trauma or iatrogenic Sphincter of Oddi dysfunction no longer represent a valid diagnostic indication for ERCP unless they cause bile duct obstruction and jaundice. Therapeutic Any of the above when the following may become necessary Endoscopic sphincterotomy (both of the biliary and the pancreatic sphincters) Removal of stones Insertion of stent(s) Dilation of strictures (e.g. primary sclerosing cholangitis, anastomotic strictures after liver transplantation) Contraindications Absolute contraindication: The uncooperative patient. Relative contraindications Recent attack of acute pancreatitis, within the past several weeks. Recent myocardial infarction. Inadequate surgical back-up History of contrast dye anaphylaxis Poor health condition for surgery. Severe cardiopulmonary disease. URETHROGRAM : URETHROGRAM CYSTOGRAM : CYSTOGRAM IVU (intravenousurography) : IVU (intravenousurography) Intravenous urography is a test which x rays the urinary system using intravenous dye for diagnostic purposes.(Antegrade pyelography) Retrograde studies : Retrograde studies “Retrograde pyelography," which injects dye into the lower end of the system, therefore flowing backward or "retrograde." Retrograde pyelography is better able to define problems in the lower parts of the system and is the only way to get x rays if the kidneys are not working well. IVU : IVU Preparation Emptying the bowel with laxatives or enemas prevents bowel shadows from obscuring the details of the urinary system. An empty stomach prevents the complications of vomiting, a rare effect of the contrast agent. Therefore, the night before the IVP the patient will be asked to evacuate the bowels and to drink sparingly. IVPs are most often done to assess structural abnormalities or obstruction to urine flow Film Sequence : Film Sequence Preliminary film (Control), (35 x 43cm) supine full A.P. abdomen to include lower border of symphysis pubis and diaphragm, to check, abdominal preparation, exposure values and for any calcifications overlying the renal tract areas. Contrast Media InjectionThe median cubital vein is punctured with a 19 gauge needle and the warmed (40*C) contrast agent is injected rapidly. Films are then taken at intervals to demonstrate the whole of the renal tract. Contrast used in IVU : Contrast used in IVU Nephrogram : Nephrogram End of Injection,A.P. of the renal areas to show the nephrogram, i.e. the renal parenchyma opacified by the contrast medium in the renal tubules. 5 Minute film, (24 x 30cm) A.P. : 5 Minute film, (24 x 30cm) A.P. A.P. of the renal areas to determine if excretion is symmetrical or if uptake is poor and a further dose of contrast agent is required. 15 Minute film : 15 Minute film (35 x 43cm) demonstrate the pelvicalyceal systems and the ureters. 25 Minute film : 25 Minute film (24 x 30cm) 15° caudal angulation centered 5 cm above the upper border of the symphysis pubis to demonstrate the distended bladder Post Micturition film : Post Micturition film (24 x 30cm) 15° caudal angulation centered 5 cm above the upper border of the symphysis pubis to demonstrate the bladder emptying success, and the return of the previously distended lower ends of ureters to normal. RENAL SCINTIGRAPHY : RENAL SCINTIGRAPHY (DTPA) scan : (DTPA) scan Diethylene triamine pentaacetic acid DTPA SCAN/MAG 3 SCAN : DTPA SCAN/MAG 3 SCAN A MAG3 scan is a diagnostic imaging procedure that allows a nuclear medicine physician or radiologist to visualize the kidneys and learn more about how they are functioning THYROID SCAN : THYROID SCAN MRI : MRI MRI FOR FISTULA INA ANO MRI is used in a wide variety of situations, including the investigation of: nerve conditions (including the brain) heart and vessel function diseases of the liver and bile ducts chest imaging orthopaedic conditions, such as shoulder injury, hip injury. CT ABDOMEN/WITH OR WITHOUT CONTRAST/EMI SCAN/CAT SCAN : CT ABDOMEN/WITH OR WITHOUT CONTRAST/EMI SCAN/CAT SCAN Computed tomography (CT) scans are completed with the use of a 360-degree x-ray beam and computer production of images PET Scan : PET Scan (Positron Emission Tomography) A PET Scan (or Positron Emission Tomography) is a non-invasive, diagnostic examination that finds information about the activity of different parts of the body. Those parts of the body that are the most active need energy, and the energy that it uses is sugar (glucose). A PET scan uses a specially created substance that the body thinks is sugar, and takes up into the cells. This substance is called a 'tracer', and it is almost exactly like sugar, but has a small radioactive part attached to it. The images are based on the detection of radiation from the emission of positrons (positively charged electrons) from this radioactive tracer. The subsequent images created are used to evaluate a variety of diseases, with the most common use being whole body imaging of cancer. : A PET Scan (or Positron Emission Tomography) is a non-invasive, diagnostic examination that finds information about the activity of different parts of the body. Those parts of the body that are the most active need energy, and the energy that it uses is sugar (glucose). A PET scan uses a specially created substance that the body thinks is sugar, and takes up into the cells. This substance is called a 'tracer', and it is almost exactly like sugar, but has a small radioactive part attached to it. The images are based on the detection of radiation from the emission of positrons (positively charged electrons) from this radioactive tracer. The subsequent images created are used to evaluate a variety of diseases, with the most common use being whole body imaging of cancer. Limitations of a PET Scan : Limitations of a PET Scan PET scans can sometimes show up areas of high activity which may be mistaken for cancers. Inflammatory conditions like rheumatoid arthritis or tuberculosis absorb a lot of the tracer, and so can cause confusing results. A PET scan is less accurate in certain situations: Slow-growing, less active tumors may not absorb much tracer. Small tumors (less than 7mm) may not be detectable. High levels of blood sugar can cause the cells to absorb this normal sugar rather than the radioactive, injected kind.. The radioactive substance has a very short decay and therefore appointments must run on schedule. PET scans are a very expensive form of imaging, and are not readily available. They often accompany other scans such as CT and MRI in order to be diagnostically effective. wireless capsule enteroscopy : wireless capsule enteroscopy a pill sized video capsule is swallowed, which slowly travels through your bowels before being naturally excreted several hours later. The capsule has its own built-in light and camera to take pictures of the walls of the bowel and detect obscure bleeds or small bowel tumours, ulcers or abnormal vascular masses. 2-4 images are taken per second for up to 8 hours. The images are transmitted to a recorder that is worn around the waist. Benefits of a PET ScanPET scans are beneficial as they demonstrate the biochemical changes in the body, whereas a CT or MRI scan identifies anatomical changes.A PET Scan therefore helps to identify problems at the level of their activity and function, which might change long before any changes in body structure (such as a tumor) become apparent. This allows for earlier diagnosis and more effective treatment of diseases such as cancer, and also more detailed imaging of other conditions. There is little risk involved with the intravenous administration of the radioactive "tracer" as the tracer has a short decay time of only a few hours and is quickly removed from the body. : Benefits of a PET ScanPET scans are beneficial as they demonstrate the biochemical changes in the body, whereas a CT or MRI scan identifies anatomical changes.A PET Scan therefore helps to identify problems at the level of their activity and function, which might change long before any changes in body structure (such as a tumor) become apparent. This allows for earlier diagnosis and more effective treatment of diseases such as cancer, and also more detailed imaging of other conditions. There is little risk involved with the intravenous administration of the radioactive "tracer" as the tracer has a short decay time of only a few hours and is quickly removed from the body. THANK YOU : THANK YOU

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