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