An X-ray was taken in a 30 year old male who presented with a history of left sided chest pain. What is the finding is the X-ray given above? What is the condition that caused the above finding. What are the clinical features?

Note: The finding may not be related to the presenting complaint.

Image Credits : Radiopedia

1. Radiology – Case 2
2. SPM – MCQ 11 – Case finding in RNTCP
3. Radiology – Case 1

The Xray given above was taken in a 37 year old patient who presented with acute colicky abdominal pain. Spot the diagnosis! How many air fluid levels are normally seen? Which are the normal sites where air fluid levels are seen?

The X-ray shows multiple air fluid levels. This finding combined with the history of colicky abdominal pain points towards the diagnosis of acute obstruction of small bowel. The obstruction may be due to adhesion, hernia, neoplasm, foreign body etc. Studies have shown that a normal person has on average 4 air fluid levels. Most of them are seen in the colon.  For the diagnosis of small intestinal obstruction, we should see more than 2 air fluid levels among the dilated loops of small bowel.

Image credits: James Heilman, MD (Wikipedia)

1. Radiology – Case 1
2. Multiple air-fluid levels in intestinal obstruction
3. Mucous fistula – definition

An 41 year-old male presented to the emergency department with the sudden onset of severe epigastric pain. He had a history of heart burn and dyspeptic symptoms for past 10 years. On physical exam, he had a temperature of 101.4°F, a pulse of 118 and a blood pressure of 128/72. Abdomen was tender with board like rigidity. An X-ray was taken to confirm the diagnosis.

What is the diagnosis revealed in the X-ray given above? What are the other conditions that can produce this sign?

 Answer:

X-ray shows gas under diaphragm – pneumoperitoneum. From the history and the X-ray findings, this is probably a case of perforated peptic ulcer.

Causes of gas under diaphragm are:

• Perforated peptic ulcer
• Small bowel perforation
• Ruptured diverticulum
• Penetrating injury to bowel
• Necrotising enterocolitis/Pneumatosis coli
• Bowel malignancy
• Ischemic bowel
• Steroids
• After laparotomy / laparoscopy
• Breakdown of a surgical anastomosis
• Peritoneal dialysis
• Vaginal insufflation (air enters via the fallopian tubes as in tube patency testing)
• Colonic or peritoneal infection
• From chest (e.g. bronchopleural fistula)
• Non-invasive PAP (positive airway pressure) can force air down duodenum as well as down trachea

Image credit : Clinical_Cases (wikipedia)

1. Radiology – Case 2
2. Free gas under the diaphragm – Xray
3. Radiology – Case 3

Click on image for an enlarged view

• The normal indentations of the esophagus seen in a right anterior oblique view during barium swallow are made by (from above downwards):
  • Aortic arch – 22.5 cm from incisor teeth
  • Left bronchus – 27.5 cm from incisor teeth
  • Left atrium
• Clinical importance:
  • In olden days, when echocardiography was not available, this was used to detect left atrial enlargement in cases of mitral stenosis
  • When left atrium is enlarged, it may compress on the esophagus and cause dysphagia – known as cardio esophageal syndrome

1. Constrictions of oesophagus
2. Radiological signs in mitral stenosis
3. Normal chest X-ray

1. Radiological signs in mitral stenosis
2. Multiple air-fluid levels in intestinal obstruction
3. Surgery – MCQ 8 – Preferred incision for abdominal exploration in Blunt injury abdomen

Kerley B lines are short horizontal white lines seen in chest X-ray produced by distended interlobular septa.

Features of Kerley B lines:

• Short – about 1-2 cm long
• Seen close to the pleura and perpendicular to it
• Individual lines are parallel to each other
• Usually seen at the lung bases near costophrenic angles in postero-anterior view radiographs / at the substernal region in lateral radiographs

Mechanism:

• Fluid accumulation between the secondary lobules of the lungs in pulmonary oedema

Other causes of septal lines:

• Conditions producing lymphatic obstruction – sarcoidosis, lymphangitis carcinomatosa

1. Radiological signs in mitral stenosis
2. Anatomy – MCQ 27 – Two cell lines derived from two different zygotes
3. Apical lordotic view in chest X-ray

• X-ray chest posteroanterior view showing homogenous haziness in left lung – upper and mid zones
• Elevation of left dome of diaphragm – due to volume loss secondary to bronchus obstruction / diaphragmatic palsy secondary to phrenic nerve involvement
• Mediastinal shift to left side
• Hyperinflated right lung

Impression - Bronchogenic carcinoma

Factors in favour of diagnosis of bronchogenic carcinoma

• Homogenous haziness (Tuberculosis can cause haziness of upper zone – due to fibrosis, but the appearance is non homogenous)
• Volume loss can occur due to compression of bronchus by the tumour
• Mediastinal shift due to volume loss
• Phrenic nerve infiltration can cause diaphragmatic palsy

1. Pleural effusion – left
2. Tracheal shift to right on X-ray chest PA view
3. Posterior mediastinal mass

Spondylotic changes to look for in lateral view radiograph of neck:

• Osteophytes
• Disc space narrowing
• Loss of cervical lordosis
• Uncovertebral joint hypertrophy
• Apophyseal joint osteoarthritis
• Decreased vertebral canal diameter

Other imaging modalities for diagnosing cervical spondylosis:

• CT scan
• CT myelography
• MRI – investigation of choice

1. Anatomy – MCQ 14 – Difference between typical cervical & thoracic vertebrae?
2. Forensic medicine – MCQ 8 – Shape of nulliparous cervical canal
3. Orthopaedics – MCQ 38 – Fracture dislocation of cervical spine

Scoliosis is a deformity of the spine which is characterised by lateral curvature of the spine in upright position in the coronal plane

Problems due to scoliosis:

• Cosmetic
• Deranged force and load transmission through spine
• Impairment of functioning of vital organs like heart and lungs
• Difficult to treat

Types of scoliosis:

• Structural
  • Fixed curvature
  • Non flexible
  • Does not get corrected by side bending
• Non structural
  • Flexible curvature
  • Gets corrected by side bending

Mechanism of non structural scoliosis

• Compensatory – to compensate for leg length deformities / fixed flexion deformities of hip
• Sciatic – due to inflammation / irritation due to lumbar disc disease
• Postural – due to bad posturing

1. Tension band principle
2. Mass lesion – Left lungs – X-ray
3. Dermatology – MCQ 23 – 27 year old male with vesiculobullous lesion

Causes of hilar lymphadenopathy:

• Infections (eg: Tuberculosis)
• Granulomatous diseases (eg: Sarcoidosis, Wegener’s granulomatosis)
• Neoplasms (eg: Bronchogenic carcinoma)

1. Medicine – MCQ 154 – Conditions causing increase in serum angiotensin converting enzyme
2. Mass lesion – Left lungs – X-ray
3. Massive pleural effusion

• X-ray chest anteroposterior view showing massive pleural effusion on left side and mediastinal shift to right
• Patient presented with symptoms of dyspnoea, cough and fever for 1 week duration
• On examination, breath sounds were absent on left side with stony dullness on percussion
• Patient’s spouse was an active case of tuberculosis, hence tuberculous pleural effusion was suspected

1. Pleural effusion – left
2. Minimal pleural effusion
3. Urinothorax – Etiology, Clinical features and Management

(Click on  image for an enlarged view)

• Compression fracture of the anterior part of vertebral body occurring in forward flexion
• Usually does not produce neurological deficits
• It is a stable fracture as only the anterior column of spine is involved
• Caused by : Road traffic accidents, Fall from height
• Predisposing factors : Osteoporosis

1. Denis’ three column concept of spine stability
2. Healed fracture rib
3. Orthopaedics – MCQ 38 – Fracture dislocation of cervical spine

(Click the above image to view an enlarged version)

1. Mass lesion – Left lungs – X-ray
2. Normal indentations on the esophagus in barium swallow – Right anterior oblique view chest X-ray
3. Tracheal shift to right on X-ray chest PA view

Continuos left hemidiaphragm sign in lateral view

Air anterior to heart in pneumomediastinum

Halo sign in pneumopericardium

1. Radiological signs in mitral stenosis
2. X-ray skull lateral view
3. Normal chest X-ray

Minimal pleural effusion R

Click on the image for a larger view

Minimal pleural effusion on the right side seen as obliteration of right costophrenic angle. Even such small pleural effusions will measure about 300 ml of pleural fluid.

1. Pleural effusion – left
2. Massive pleural effusion
3. Tracheal shift to right on X-ray chest PA view

Radiograph showing mastectomy of left breast. The breast shadow is visible on the right side, whereas it is not seen on the left side.

1. RGUHS Karnataka PGET 2011 – MCQ 48
2. Mass lesion – Left lungs – X-ray
3. Pleural effusion – left

Apical lordotic view in chest X-ray

An apical lordotic view of chest x-ray used to taken to visualise the lung apices better, to look for apical tumours like Pancoast tumour or superior sulcus tumour and apical tuberculosis. In the usual chest x-ray, this region is partially covered by the clavicles, while in the apical lordotic view the clavicles are away from the field. This view is seldom used now a days because of the frequent availability of CT scans which provide much superior diagnostic information.

1. Tracheal shift to right on X-ray chest PA view
2. Normal chest X-ray
3. X-ray skull lateral view

Destruction of anterior end of 2nd rib (right)

1. Biochemistry – MCQ 80 – Proteins targeted for destruction
2. Posterior mediastinal mass
3. Unfolding of arch of aorta

Posterior mediastinal mass seen in left upper zone

Posterior mediastinal mass seen on scout scan seen in the left upper zone

 

Posterior mediastinal mass on CT scan, to the left of the vertebra

1. Mass lesion – Left lungs – X-ray
2. Mass lesion – Chest X-ray
3. Unfolding of arch of aorta

X-ray skull lateral view

In the field of general medicine, X-ray skull lateral view is often obtained to see the pituitary fossa and also to look for punched out osteolytic lesions in multiple myeloma.

1. Apical lordotic view in chest X-ray
2. Tracheal shift to right on X-ray chest PA view
3. Pyriform aperture

Unfolding of arch of aorta

Unfolding of arch of aorta, a common finding in elderly. It appears like a superior mediastinal widening.

1. Posterior mediastinal mass
2. Rotated chest x-ray
3. Apical lordotic view in chest X-ray

Ankle brachial index = 1.2

Ankle brachial index is useful to evaluate the status of the peripheral vasculature, especially in diabetic individuals. Ankle brachial index is the ratio of the ankle systolic blood pressure to the brachial systolic pressure.

1. Doppler tracings of limb arteries
2. DNB June 2011 – MCQ 7
3. Cardiac Index

Brachial and ankle Doppler tracings

Doppler tracings from brachial artery, posterior tibial artery and dorsalis pedis arteries.

1. RGUHS Karnataka PGET 2011 – MCQ 83
2. Ankle brachial index
3. Digital artery Doppler flow pattern

Medial perforators of saphenous venous system

1. Rotated chest x-ray
2. Destruction of 2nd rib
3. Bilateral cervical rib

Ultrasound image of subcutaneous edema

1. Colour Doppler imaging of popliteal artery and vein
2. Radiology – MCQ 30 – Ultrasound marker for Trisomy 21
3. Cerebral hemorrhage

Digital artery Doppler flow

1. Colour Doppler imaging of popliteal artery and vein
2. Femoral artery Doppler pattern
3. Doppler tracings of limb arteries

Colour Doppler image of popliteal artery and vein

Longitudinal ultrasound image of the popliteal artery and vein with colour flow mapping. Blue colour indicates flow away from the transducer and red colour indicates flow towards the transducer. The light green quadrilateral is the colour Doppler sample volume. The vein appears larger than the artery in the two dimensional ultrasound image.

1. Digital artery Doppler flow pattern
2. Femoral artery Doppler pattern
3. Doppler tracings of limb arteries

Femoral artery Doppler pattern

(Click on  image for an enlarged view)

Doppler ultrasound tracing from the left femoral artery is seen the lower panel. The tall upward component is the predominant systolic flow. The graduation at the right end is the velocity in cm/sec. The upper panel shows the longitudinal image of the femoral artery seen as a dark longitudinal shadow in the middle of the image. The imaging line with cursor within the lumen of the femoral artery is also seen in the upper panel.

1. Digital artery Doppler flow pattern
2. Colour Doppler imaging of popliteal artery and vein
3. Deep branches of femoral artery – Mnemonic