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89 Cards in this Set

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free air w/in peritoneal cavity
pneumoperitoneum
types of pneumoperitoneum
laparotomy w/in 3-7 days
spontaneuous
traumatic
m/c cause is perforation of gastric or duondenal ulcer
spontaneous pneumoperitoneum
secondary to diagnostic studies
perforation fm barium enema/colonoscopy
severe external trauma
traumatic pneumoperitoneum
free air under hemidiaphragm
radiographic signs of a pneumoperitoneum
intraluminal and extraluminal air outlining both surfaces of bowel wall
double wall sign AKA Rigler's sign
triangular gas density projected over superior margin of right kidney
represents air trapped dorsally under liver
Morrison's pouch sign
two closely approximated loops of bowel mimic a Rigler sign
double wall finding
gas filled loop on intestine between liver and diaphragm
Chilaiditis syndrome
gastric air bubble is under right hemidiaphragm
situs inversus
fat under diaphragm
subdiaphragmatic fat or extraperitoneal fat
Mucosal folds in sm intestine normally 1-2mm in width & regularly spaced
valvulae conniventes
small bowel rule of 3
no more than 3 air/fluid levels
no more than 3 cm of bowel distention
no more than 3 mm between folds
small bowel obstruction clinical findings
nausea, vomiting, cramping, abdominal pain, distention
may be partial or complete
adhesions fm surgery m/c
hernias
neoplasms
intussusception
strictures fm Crohn's disease
volvulus
mechanical bowel obstruction
sm bowel tries to force obstruction out by strong peristaltic contractions
may be seen as dynamic motion on surface of abdomen
Dynamic Ileus
bowel becomes exhausted and stops peristalsis
air collects in dilated loops of bowel
Adynamic Ileus
fairly common in adults occasionly children
indirect>direct M>F
presence of enlarged scrotum that contains multiple loops of air filled bowel
Inguinal hernia
common in adults
stomach herniates thru diaphragmatic hiatus
hiatal hernia
gastroesophageal junction remains fixed and gastric fundus herniates
Paraesophageal (1%) hiatal Hernia
m/c (95%) gasatroesophageal junction slides upward
Sliding hiatal hernia
three types of hiatal hernia
sliding
paraesophageal
mixed
gastroesophageal junction at 2 cm above diaphragm
soft tissue mass or air fluid level in middle/posterior mediastinum (retrocardiac region)
radiographic findings for hiatal hernia
two types of pathological calcifications
metastatic
dystrophic
refers to calcium deposition in normal tissue
result of hypercalcemia/elevated pH
not frequent in abdomen
apppears as a cloud of calcium deposits
described as tumoral calcinosis
metastatic calcification
occurs in local tissue damage or stone formation
normal calcium/pH
very common in abdomen
Dystrophic calcification
dystrophic calcification classifications
morphological features
location
mobility
radiographic features of dystrophic calcifications
what to look for
shape, border sharpness, marginal continuity, internal architecture
four types of dystrophic calcifications
concretions
conduit wall
cyst wall
mass
called stone or calculus
calcified mass that forms inside tubular or hollow structures
forms like pearl
concretion
sharp
clearly defined external margins
continuous
internal architecture:laminations, eccentric area of lucency, homogenously dense
radiographic appearance of concretions
found in appendix
associated w/current or future perforation
associated w/pain 90% chance of acute appendicitis
appendocolith
RUQ
solitary or multiple
"bag of Diamonds"
only 10-15% calcify & show up on xray
can be multifaceted
cholelithiasis
gallstones
m/c associated w/pancreatitis d/t alcoholism
caused by long standing ductal obstruction/inflammation
multiple,tiny, dense,discreet opacities
cross midline at L1-2
pancreatic calculi
m/c calcification in pelvis
calcified thrombus w/vein
normal variant
multiple/bilateral
do not cross midline
phleboliths
multiple calcifications ,various sizes, behind pubic symphysis in males
prior prostatitis
asymptomatic usually
prostatic calculi
seen in: renal calyces, renal pelvis, ureters, bladder
most calcify 85-95% visualized on xray
chronic low-level dehydration/infection
mineral deposit embedded in inorganic material
asymptomatic til obstruct
calcium phosphate, calcium oxalate, magnesium phosphate
(struvite) m/c
urinary tract calculi
large stone occupies renal collecting system forming cast of major calyces and renal pelvis
usually struvite (triphosphate)
may cause chronic hydronephrosis
leading to renal failure
staghorn calculus
seen on plain film present w/ low back pain, flank/groin pain
look in kidney, ureters, bladder
m/c lodged in uteropelvic junction, bifurcation of iliac vessels, uterovesical junction
radiographic findings for renal stones
round
central lucency
below ischial spine
DOES NOT MOVE
phlebolith
irregular shape
uniformly dense
above ischial spine
Moves w/time
renal stone
caused by obstruction/infection
may be migrant renal stone
50% may be seen on plain film
stellate referred to as "jackstone"
bladder stone
stellate bladder stone
jackstone
tubular structures thru which fluids are conducted
calcifications confined to tubular walls
m/c arterial walls
conduit wall calcifications
parallel, linear opacities (tract-like)
dot-dash appearance
may see vessel branch pattern
seen on end appear as ringlike
radiographic finding for conduit wall
m/c result of atherosclerosis
*smoking, diabetes,hypertension
m/c below renal arteries
NOT contraindication to manipulation
Not always an aneurysm
Abdominnal aorta calcification
m/c athersclerosis
M 4:1
older pts 95% 60-80yrs
asymptomatic
pain in low back,buttock, down leg
abdominal mass or pulsation
abdominal pain
aneurysms
3cm-3.8cm=dilation
>3.8-suggests aneurysm
4.5cm-6cm=surgical consult
>7cm=immediate consult
Abdominal aortic size
abdominal ultrasound
CT
diagnostic for aneurysms
second m/c site for arterial calcification
easy to recognize
may undergo aneurysmal changes
second to abdominal aorta
iliac artery calcification
arise fm abdominal aorta at or near L1 and extend laterally
athersclerosis or diabetes
typically aorta calcified as well
renal artery calcification
frequently calcifies
serpentine course in LUQ
very tortuous (may appear ringlike)
may be dilated or aneurysmal
splenic artery
duct that carries sperm fm epididymis to urethra
m/c associated w/diabetes
bilateral/symmetric
forms "V" shape
parallels pubic rami
vas deferens calcification
calcium deposition w/in wall of abdominal fluid filled structure
smooth, curvilinear rim opacity
complete or incomplete borders
displace or distort adjacent vessels/organs
cyst wall calcifications
2/3 splenic cysts caused by echinoccocus (hydatid cyst disease)
uncommon in US
accidental oral ingestion of eggs
cysts form in solid organs:liver, spleen, lung, brain
may have daughter cyst
echinococcal cyst (hydatid)
calcification of gallbladder wall
d/t chronic inflammation
females ages 38-70yrs
10-20% develop gallbladder carcinoma usually aggressive poor prognosis
porcelain gallbladder
most diverse presentation of abdominal calcifictions
irregularly calcified borders & complex internal architecture
may occur anywhere in abdomen
central or peripheral , adjacent to or w/in organs
solid mass calcification
4 standard differential for masses
calcified mesenteric lymph nodes
leiomyoma
dermoid cyst (teratoma)
injection granulomas
occur along broad arch fm LUQ to RLQ w/in small bowel mesentery
multiple of varied sz
TB and Histoplasmosis m/c causes
Mesenteric lymph node calcification
m/c women
usually occur in uterus can be anywhere
benign tumor of smooth muscle
whorled type of calcification or flocculant
may demonstrate prominent bordering rim
Leiomyomas
subcutaneous fat necrosis secondary to intramuscular injections
m/c in hip soft tissue
solitary or multiple calcific spheres
injection granulomas
stone baby
calcified fetus body could not resorb
lithopedion
Stands for kidneys, ureters and bladder
Represents the “standard” radiograph
Sometimes referred to as a flat plate
70kVp if looking for calcification
90kVp if looking for a mass
KUB study
Taken with the same parameters as the KUB
Only the patient is lying on the abdomen (prone)
PA is anterior anatomy while a KUB is designed for the posterior anatomy
PA abdominal study
The very best to demonstrate free intra-abdominal air is the PA chest (erect)
Air will travel to the location of least resistance
Fluid will gather in the most gravity dependent area
pneumoperitoneum study
Patient lays on their side with their back up against the film
Patient should be on their side for a minimum of 5 minutes before exposure
Left Best demonstrates free air within the abdominal cavity in the area of the liver in the RUQ
Lateral Decubitus Position
Taken just like an AP lumbar film
70 kVp for calcifications
90 kVp for masses
Fluid sinks down to the pubic area
Air travels up to the diaphragms
AP Abdomen—Erect
Patient lays on their back with their side up against the film
Looks just like a lateral lumbar
Asses for free air/fluid and aneurysms
Dorsal Decubitus
Abnormal gas and mucosal patterns
Morphological abnormalities of the anatomy
Abnormal calcifications
Abnormal fluid (ascites)
Bone and joint abnormalities
Post-operative changes
Pathological Considerations of abdomen
Mostly located in the LUQ
Identified by the gas content or meganblase (gastric air bubble)
Relatively fixed position at the gastroesophageal junction while the rest is fairly mobile
stomach
Duodenum is primarily a fixed retroperitoneal structure
The descending (2nd) portion is closely associated with the head of the pancreas
Typically does not contain enough air to be visualized on plain film radiographs
Valvulae conniventes– are the circular folds
small intestine
Relatively well visualized because of its gas content
Haustra (semilunar folds)
Cecum usually found in the RLQ
Can be mobile
Ascending and descending portions are retroperitoneal
The rectum typically is seen with air within it
Presacral space—the distance between the anterior cortex of the sacrum to the posterior margin of the recutum
Should not exceed 2cm in adults
Exception in the extremely obese
Causes for increased: inflammation, ascites, blood, neoplasm
Seen on a lateral image
large intestine
Generally not seen unless pathological
Diagnostic ultrasound is the preferred method of investigation
CT has also been shown to be more sensitive and accurate
Traditional located in the RLQ
appendix
RUQ
Homogenous water density
There should be no gas separation between the liver and right hemidiaphragm or within the liver
Reidel’s lobe:
Congenital anomaly
Vertical elongation of the inferior margin
May extend down to the iliac crest
Common in tall thin females (3-30%)
liver
Closely associated with the anteroinferior aspect of the liver
One of the more common sites for abnormal abdominal calcifications
(cholelithiasis)
wall calcification may result in carcinoma
Not always visualized
RUQ
There is some variability
gallbladder
One of the more difficult organs to visualize
Head lies within the duodenal loop
The tail projects posteriorly and to the left
Chronic pancreatitis may demonstrate calcficiations
pancreas
Located within the LUQ
Superiorly it is bordered by the left hemidiaphragm
Only the lower pole casts a shadow on the radiograph
Vertical Height (8-12cm)
Measure 2cm up from the inferior pole for the horizontal measurement
Measurement should be no more than 4cm
When enlarges it will travel in an anterior and inferior direction
Measurements on plain film radiographs are not completely accurate
spleen
Bean-shaped
Located with in the retroperitoneum
Slight medial inclination towards the upper poles
Patient position and respiration can change the position
Superior pole is found at T12/L1
The length is no more than the combined height of 3.5 vertebral bodies
Left sits higher than right by 1-2cm
Dromedary Hump: Seen on the left Caused by the spleen pushing on the side creating a “hump”
kidneys
Bilateral V-shaped organs
Superior and somewhat anterior to the superior poles of the kidneys
Not demonstrated on plain film normally
adrenal glands
Not normally seen on plain film
Retroperitoneal
Most common site for symptomatic calculi
Three common sites for calculi to lodge
Ureteropelvic junction
The point where they cross the bifurcation of the iliac artery
Ureterovesicular junction
ureters
Comes off the transverse processes of T12 and descends to the iliac crest
What is actually seen is the interface between the actual muscle and the fat surrounding it
Non-visualization may reflect serious disease like inflammation or ascites as well as benign reasons
Excessive overlying gas
Curvature of the spine
Lack of surrounding fat
Psoas shadow
Outlines the margins of the abdomen lateral to the ascending and descending colon
It appears as a lucent line separating the soft tissues of the skin from the abdominal cavity
This line is often obliterated in inflammatory conditions of the abdomen such as
Appendicitis
Peritonitis
flank stripes
Seen as a water density immediately superior to the pubic symphysis
In females, the uterus may lay against the superior aspect causing an indentation
bladder
Located in the pelvic bowel
Between the rectum and bladder
Seen only if it indents the bladder
May contain calcifications within uterine fibroids
uterus
Located in the pelvic bowel
Exact location varies
Not typically seen on plain film
ovaries
Located with in the pelvic bowel
Not visualized unless calcified
Most often seen in diabetic patients
male
vas deferens
Lies just above the pubic symphysis
Normally not seen
Calcifications from prior inflammation
male
prostate
Runs along the left anterolateral aspect of the lumbar spine
Bifurcates into the iliac arteries at approximately L4/L5
Calcification more common in elderly
Upper limits of normal is 3.5cm
abdominal aorta
Branch at L4/L5
Extend down and out to the groin
Common site for calcification
common iliac