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Yeah. Mhm. Hi, everyone. My name is kept on, and I'm one of the doctors in South Yorkshire in the UK I'm hoping Well, I've seen some of you before, but if not, then welcome to the next Webinar in the minor Blips Radiology series. So over November, December and January, we aim to cover pretty much all the imaging modalities that doctors and healthcare professionals will come across in the hospital and are expected to be able to have some idea of how to interpret. So last year, Doctor Murari took us through the chest X rays, which is probably the most common plain film request in the hospital. And tonight, doctor friend Hughes will take us the restriction approach to the abdominal and pelvic X rays, which are two of the also more commonly requested plain films and hospital. And often do you find them quite difficult to interpret. So she'll go through a logical approach to interpreting both these plain films, and we'll discuss some cases with you. Um, so we'll just crack on with it then. So, Fran, I'll hand over to you. That's right. Yeah, that's fine. Um, so as Kevin said, my name is Francis use. And I'm one of the radiology registrars in in Sheffield in the UK Um, so we're going to have a quick look through how to approach abdominal and pelvic X rays. Um, we're going to start with abdominal X rays. Um, we have a quick note on why these X rays are performed. Um, go through some of the important signs, mainly things that are going to be relevant to any junior doctors working on wards. And then we're going to talk through a system for reviewing all the different areas of both of the types of X ray. So we'll start with abdominal X rays. Um, they are, as Kevin said, one of the more common types of plain film that are done. However, they have become a lot less frequent now that we have CT for assessing acute abdomen. But they are still important and do feature especially, um, in specialties such as surgery and acute admissions. Um, the main indications these days are to evaluate bowel gas. So patterns of bowel gas looking for evidence of of perforation in the GI tract. So looking for free gas, um, they're also done for calculi, usually renal calculi monitoring, um, other things such as lines and tubes, um, sometimes done for foreign bodies that have been swallowed, etcetera, and sometimes again for suspected bowel obstruction or less post surgery. So when people talk to me about the abdominal X ray, I often feel like this little trap pretty scared. Um, as many of you might do. So, um, I don't know if any of you familiar with the website Radio Pedia, but it's a really useful resource for radiologists. And their favorite method for abdominal plain film is the Abdo X method. So Abdul X stands for air bowel densities, organs and soft tissues and external objects. So we'll start at the top with their, uh So the first thing to sort of establish is where should we see? Uh, on the on the abdominal X ray, Where is it normally? So normally we'll see, uh, in the GI tract. So this will be in the stomach. So under the left hemidiaphragm just over here, and then we should see a within the large and small bowel. So here we can see some air on this normal radiograph outlined around the periphery. This will be in the large bowel and any small patch of hair within the center are likely in the small bowel. We'll go through that in a bit more detail later on in the presentation. So one of the main things that we're concerned about with abdominal X rays is air that's free within the peritoneum pneumoperitoneum free gas. And that's a concern because it's a sign of perforation of the GI tract. So, for example, a perforated duodenal also or a perforated appendicitis, Um, the most common and the gold standard investigation for free abdominal area is the chest X ray, which you might have already known and may have been through. Um, this is an example of an erect test that has free air gas under the diaphragm because gas will rise up to the top under the diaphragm when the patient's, uh, erect and up right? So that's one form on the abdominal plain film. One of the common findings is what we call regular sign. It was quite hard to find a really obvious example of this, so I've shown it again on a red chest chest radiograph. You can see the free air again under the diaphragm, but you can also see on this side you can see that you're seeing the outline of both walls of the bowel, and this is nice and marked with some areas on this example that I borrowed, Um, so it just makes it a little bit more obvious. And regular sign is when we see a rep on either side of the bowel or any hollow, viscous like the stomach. So that just highlights that there's free air. There are a couple more signs that, um are useful in pneumoperitoneum, so the next one is more commonly seen in Children. So this is a radiograph of of an infant, and it's called the football sign. That's where we can see this sort of spherical shape in the abdomen. It's very loose and and we can see these bulging flanks at the side. And supposedly this looks like a football. Um, I don't know how convinced you might be by that I think it looks more like a rugby ball, but it's one of the lesser, uh, seen signs. Another one to know about is the false platform ligament sign. False. A form ligament is a ligament within the liver, which separates the right and left lobe of liver. And when there's a large volume of Rio in the abdomen, uh, you'll be able to see it so you can see the top of this. Radiograph is very Lucent. We can see this white line running down the center of where the liver would be. That's the false platform ligament that's been outlined by air on either side. Again, it's more commonly seen in Children. So that's why I've used a radiograph a child. One common pitfall is what we call Kyla diabetes sign, and this is when you see gas under the right hemidiaphragm. Normally, that would be very concerning, and it would suggest that there's been a perforation. But here we can see that this looks like it's within a loop of bowel. It's very rare to have a loop of bowel come up above the liver, but it does happen as a normal variant in some people. Usually one of the best things to do is to check back at any previous radiographs that the patient has had and see if this has been seen before. But otherwise it's probably worth discussing something like that with the radiologist just to make sure that you're not making a mistake. So next is beef a bowel, so we'll start with the colon or the large bowel. Um, how we identify this on an abdominal radiograph is that it's usually located peripherally. I've used this example Radiograph, where it's been outlined in red just to make it a little bit clearer, we're expecting to see the large bowel. The other feature that you'll see is how stroke, which are the folds within the bowel. And they will be, um, discontinuous. So they will be. You won't see them going completely across the wall of the bowel. They're like interrupted lines, and we'll see some examples of that in a minute. Um, the other thing that will help us to distinguish it is that it should be filled with air or fecal matter. So this is an example of a very dilated large bowel just to make some of those features clear. So it's running around the periphery, and if we look quite carefully, we can see some of these. How strict. So one of those is here. It's not going all the way across. The bowel wall is just going into the center and we can see them running all across it. So moving on to the small bowel, small bowel is located more centrally. It's highlighted here in blue in some areas on this radiograph. The other feature is valvular. Combivent is which are the folds right across, Um, the full length of the small bowel. Uh, this gives us when there's obstruction. We'll see that what we call a stack of coins sign. So this is a very enlarged small bowel, and you can see those folds running right across all the way across the diameter of the battle. And they said to give us a stack of coins appearance. So, thinking about the bowel, um, and how large it should be. It's quite hard sometimes to tell whether the bowel is dilated or not. So we tend to use the 369 rules, which is very simple, rough way to look at it, so the small bowel should be less than three centimeters. If it's above that, then it's probably dilated. The large bowel. It should be less than six centimeters, and the cecum should be less than nine centimeters. So if you're measuring any of these areas larger than those numbers. Then there's probably dilation of the loops. One of the final things to talk about with the bowel is to look for bowel wall swelling. This is a little bit more subtle and maybe not as relevant when you're working on the ward, but if you can identify it, it's probably very impressive and quite helpful. So I've used this example here because it's one of the more obvious examples I could find. So what we're looking for is bowel wall swelling, which would be due to a dumb A of the bowel so usually caused by inflammatory or effective conditions. And it said to have a thumbprint appearance. And that's referring to how we can see the bowel wall looking quite sort of indented. And I think I've got a little figure just to show. It's supposed to look like the impression of the finger pointing into the bowel and you can see the wall here. The outline is much thicker than some of the other examples that we've seen. So moving onto densities that you might see on the abdomen, um, includes things like looking at the bones, um, assessing the femoral head and neck which we'll go on to a bit more detail later with the pelvis also looking for calcification and for stones, So we'll have a look at a few examples of densities. So, um, on this radiograph here, there's a very pronounced density over here. And if you can just make out here, you might have to believe me. This is the outline of the kidney. So this would be an example of a renal stone, just a narrow for a bit of assistance. Um, on this radiograph, it's not coming out so clearly. So I've I've magnet up a little bit. But here, just underneath the ribs, we can see a collection of densities. And that would be what, a gall bladder full of gallstones which would look like there's another example of some of the densities we can see on abdominal X ray. We've got a large number of opacities here in the center. These are within the medulla of the kidney. So this would be an example of nephrocalcinosis. Organs are the next thing that we look at on the abdominal films just to help us all out. I've got this image that where we have colored over the organs just help us see them a little bit better, because it can be really difficult to identify some of the soft tissue structures on the abdominal X ray. So here in purple is the outline of the liver. We've got the outline of the spleen here in pink kidneys in the center in orange, and they're often a little bit easier to see than some of the other organs. And then down in the pelvis you might. You may or may not see the bladder, depending on how full it is when it's been imaged. So we'll just have a look at a few of like the more obvious examples I could find where some of the soft tissues are abnormal. So this is a patient with hepatosplenomegaly, and it will just trace the outline of the liver. It's coming very far down into the pelvis, and then if we look over here at the spleen again, it's enlarged and coming right down almost to the island at Crest, so that would be an example of an enlarged spleen. Another example. Here, this is a very difficult to look at the abdominal X ray. I hope you'll be able to appreciate that. It's it's quite abnormal, quite a large soft tissue density structure arising from the pelvis and coming up into the center of the abdomen. And this was actually a A an ovarian mass. But it doesn't matter too much what it what the diagnosis is. It's more the principal that we're looking at that we can see that there's a really enlarged soft tissue organ there. So finally, external objects. So that's going to include things like foreign bodies that may have been swallowed medical devices and then artefacts as well from patients, clothing, jewelry, etcetera. So just a few examples of some medical devices that we might see really commonly seen here in the pelvis. We can see this little tea or Y shaped structure, and that's a a contraceptive device there in the in the uterus. Another example. Here we've got this really dense object with a with a tube, and here this is a port. So this is a metallic object, and this is actually a gastric band and the wiring and port for a gastric band. So we'll have a look at a few cases now. It would be great if people could contribute any ideas. I'm happy to go through them and go through the answer to myself. But if anyone can contribute, that would be great. Um, so we're going to start with this one, Uh, so I'll give you a bit of history. So this is a 78 year old man. He's come from a care home, and he's been admitted with a one day history of abdominal pain and increasing abdominal distention. He's not opened his bowels. For the last 24 hours, I've tried to choose one house. Quite a big abnormality. Um, so if anyone can give us any contributions, that would be great. All ideas are welcome. So I'm just having a look at the comments. It looks like a few people are mentioning by all obstruction and talking about the large bowel, so they would definitely be right. This is, um you can see that the principles that we were talking about before so the house tra the folds that don't run all the way across the bowel, just run into the center. We've got some of those here. So you correctly identified. This is part of the large bowel, the small bottle um Interestingly, this is a type of bowel obstruction. I can't measure the size of the loop. Unfortunately on here, I could have put an arrow on for you, but this this would be measuring up to 10 centimeters. So it's very enlarged. Large bowel. Um, we can see another piece of bowel in the background here running away. And that's also a piece of large bowel. We've got those folds running across, so I think a couple of people have got it on the chat now. So this is this is a sigmoid volvulus. So this is when the sigmoid colon has twisted on itself and has obstructed. Uh, this will need decompression, so it will need a rectal tube inserting. Uh, this is a classic sign on an abdominal film. It's called the Coffee Bean Sign. I'm not sure if any of you come across that before, but this is supposed to look like a coffee bean because we've got a sort of a central line central density down the middle, and that's separating the two loops of bowel that have twisted on themselves. That's great. Thanks for everyone's contributions. Case number two uh, we've got a 56 year old woman. She is five days post cholecystectomy. So she's had a gallbladder removed. Um, and she's presented with some abdominal pain, not really opening the bowels properly. Um, so if anyone's got any thoughts on this one, that would be great. So again, just looking at, um, sort of what? What what type of bowel we're seeing? Are we looking at large bowel? Are we looking at small bowel? What do you think might be causing it? Just have a quick look at the chart and see if you got any ideas. That's great. So lots of people are suggesting a postop alias, Um, so that would be a really good thought. So when I'm looking at this one, the process I would have been thinking about is I can see obviously some large dilated loops of bowel. Um, here, peripherally, you can see a big, large bowel loops that's dilated. We've got those house truffles and it's peripherally located. But then, if we look in the center, we can also see some, um, small bowel as well. That looks dilated. So we've got those lines running all the way across, and they're dilated in the middle So we've got large and small bowel dilation, and this is common postop, commonly due to an alias. So that's where there isn't a true obstruction of the bowel. But the bowel is the movement of the bowel is slowed, causing things to back up and causing a picture that looks very similar to obstruction so well done to everyone for getting that one third case on a similar theme. I'm really gonna hammer at home because these are the most important sort of cases on the ward's, Um, we've got a 40 year old lady. Um, she's got previous history of a C section and a cholecystectomy. They were both 10 and 15 years ago. She's presented acutely and well with abdominal pain and some abdominal distention. If anyone wants to give us any suggestions for this one, that would be excellent. I'll just have a quick look at the chat, see if anyone has mentioned anything yet, and if anyone can come up with what might be causing the presentation, that would be great. Mhm. What excellent. So lots of people saying small bowel obstruction. That's brilliant. That's exactly what I was hoping you would say. We've got these big dilated loops in the center. We've got the folds coming all the way across the valve. You look on the twenties, so this is a small bowel obstruction. And, yeah, one of the commonest cause of the small bowel obstruction, One of the most common hernias. This lady doesn't have a hernia, But previous surgical history. Yeah, she's gonna have likely have adhesions, especially in a young woman as well. With the surgical history so well done to everyone for suggesting that and I think this is the final case in the abdomen section. Um so history here is a 50 year old man he's presented with some left lower abdominal pain. He's also got a sort of 1 to 2 day history of abdominal distention not opening the bowels for the last 48 hours. Again, if anyone's got any suggestions and not just about the presentation, but also possibly the cause. This is a slightly more difficult, um, image. But it would be great if we could have some suggestions. I'll have a quick look at the chat, see if any ideas are coming through. Okay, so we're getting a couple of couple of ideas. Some people suggesting inflammatory bowel disease or diverticulitis. So I think they're A lot of people are thinking that there might be a sort of inflammatory component to this. So taking a look at this one again, just applying the same simple principles. So we've got a large loops of bowel throughout the abdomen. We've got those large peripheral loops with the house draw fold's coming part of the way across the bowel, so we know we've got large bowel that's obstructed can also see some small bowel loops centrally. And as I was saying on the previous film, one of the commonest causes of obstruction, um, is due too obstructed hernia. On this image, we can see quite subtle, but we can see lucency coming here, um, in the pelvis, through the objective for human. So this is actually, um, an obstruction that's secondary to a hernia. That's quite a subtle finding, and we probably wouldn't expect everyone to be able to to get that one, especially in the junior year's. But it's something certainly to look out for when you're seeing an obstruction in a patient who is presented to the surgical team, for example, quite often with hernias you can see a lucency down in the pelvis if there's a right trapped within that herniated section of bowel, so something to look out for. So thanks everyone for the contributions. We're going to move on to the pelvic x ray. Just so we've got time for some questions. At the end, we're going to have some more cases about the pelvic X ray just towards the end as well. So, um, pelvic X ray on its own is not not that commonly done. It's often done with an abdomen, but we're going to break it down into so main indications with just a pelvis would probably be pelvic trauma assessment of hip pain, which we will touch on a little bit. Um, it's an a piece of pine radiograph, which means that the patients lying down when it's taken and it's taken with the camera going front to back. So from the front of the abdomen through to the back, and we try to include from the level of the iliac crest to it's just off a word. But to the proximal Femara, right? There was no nice pneumonic that anyone suggested for looking at the pelvic. X Ray, so I've just gone through it in the way that I look at it. So first of all, I have a look at the three rings, as it were. So look at the main pelvic ring, which I've highlighted here and then the two obturator foramen, which I highlighted below here. And what I'm looking for is continuity. If there's any disruption of the ring, and then I'm going to need to look really carefully for a fracture and with them being rings, if there's a fracture in one position, then there's likely to be a fracture at another point in the ring. So when rings break, they usually break in two places, so that's the first step. We then need to have a look at the joint spaces, so there's quite a few joint spaces in the pelvis. Um, obviously, the main one is the acetabulum and the hip, the femoral head and acetabulum. So have a look and see if you can trace the acetabulum and the femoral head looking for continuity again. If you see disruption of those lines, you're thinking about a fracture. If you're quite advanced, you might be looking for degenerative disease, so if this joint space is narrowed or if it looks very irregular, then you might be thinking about osteoarthritis. Um, we've also got the sacroiliac joints here bilaterally. Um, so we're looking for symmetry of those joints. Um, they should be about 2 to 4 millimeters in in width. So any widening and you might be suspicious for a traumatic injury. Um, and then, finally looking at the synthesis pubis, it should usually be less than five millimeters wide. And if it's widened, you might be thinking about again, trauma or fracture. And you might want to look elsewhere in the pelvis for any other injuries. As I mentioned, assessing the acetabulum is quite difficult on just an AP film. Um, usually, if you think there's a hip injury, probably going to have a lateral film as well, so that would be helpful. But if you're just looking at the pelvis, um, tracing this line would be very helpful. And then, looking at the borders of the Acetabulum, these two lines here that make up the front and back of the Acetabulum are actually very hard to see on the AP plain films, so I think that would be very difficult to trace. If you can trace this main arc of the acetabulum and going down, that would be really helpful. And any disruption there would suggest a fracture and maybe mean that you'd request a lateral X ray of the hip. The other thing to look at this picture is unfortunately not come out very well. The other thing to look at is the sacrum and the sacral. A lie, the arches at the back of the sacrum. So you want to be tracing those as well? They should be smooth. They should be symmetrical on both sides. Um, any disruption is making you think about a fracture. Also assessing the proximal femur. So, um, looking for the smooth lines down the neck of the femur, looking at the trick hunters and then into the into the proximal femur. But that's probably more for an M S. K talk. One of the main lines that I look at you might have heard of because it's quite commonly talked about is centonze line. That's this curved line here that goes from the bottom of the proximal Femara and into the pelvis. It should be continuous and smooth and make this curved art. And if you see them looking asymmetrical from one side to the next, and that's quite suspicious for a fracture of the proximal femur, so it just makes you look that little bit more carefully. If you can see if you can see a fracture there so I can move straight onto some cases, Um, we'll start with Case one, um, so a bit of history. Somebody's um, 68 year old lady has come into hospital following a full, and she's got some pain in the left hip. Try to choose some quite obvious abnormality, so they'll project well. So if we could have people's ideas, that would be great. Um, I'll take a look at the chat in a second, and we can just have a talk through some of the things I was mentioning. When you're assessing the plain films while we get some answers come through. So first of all, assessing the main pelvic ring. So when we do that on this film, see that there is some asymmetry, especially in this region. Then we'll be tracing the obturator foramen. This one is not very clearly seen because of the angle, um, then tracing the joints. So the sacroiliac joints here they look nice and symmetrical, tracing the synthesis pubis again look symmetrical and not too wide tracing the hip on this side and then also on this side around the femoral head. I'll take a look at the chart now see if we've got any ideas before I give away what the answer is. Uh, so having a look through, lots of people have identified that there's some pathology on the left and met. Lots of people have seen that there's a fracture fracture of the neck of the femur. That's right. And one of the important features to assess on the plain film here is the positioning of the fracture. So fractures that are inter capsule, as you might have already gone through a medical school, um, intracapsular fractures of a mecca FEMA carry a high risk of disruption of the blood supply to the femoral head, which can lead to a vascular necrosis of the femoral head and poor healing. Um, so you can't see the capsule on the plain film? Not very well, anyway, um, but if we look at this normal side, you can get an idea of where the capsule would be so you might. I don't know how well this is projecting for you guys, but you might be able to see that there is a soft tissue density here and it's slightly loosened around it. And this is roughly where the capsule will be coming and inserting onto the formal head. So it's always useful to be able to tell roughly where the fracture is and just, um, a note about centonze line that we talked about before. It's always really useful when sometimes you can't tell if there's a fracture, because they can be very subtle if you trace it on this side. It's a nice, perfect arch, and here, if you trace it on this side, there's a big bump in the middle by the femoral head. It just doesn't look smooth at all. So on on subtler cases than this, that could be really helpful but identifying fractures. So that's great. Lots of people got that one. We'll move on to this one. This is just half of a plain films. I want you to zoom in a little bit, so it projected better again. This is another 70 year old male who is presented with left pelvic kind of leg pain. Um, again, I'll wait for some ideas to come through, and then we'll talk through some of the findings. I think we're getting a few few answers through now, so that's great. So if we have a look at this side getting a flurry of answers now, great. So lots of people are mentioning an intertrochanteric fracture. That's great. But anyone who's unsure about this, or or what what an intra trochanter fracture is exactly, we'll have a look through. So again, starting with sentences line you can trace start to trace it here. And then we've got this bump here, and it becomes really quite indistinct again, suggesting that there's there's a fracture here. Um, you see the femoral head sitting nicely within the acetabulum. It's not dislocated, but if we go a little bit further along the neck, it all just becomes a little bit difficult to trace around the outside of the hips or just a little bit fragmented. We can see some loosened lines here, and then if we go to a female, we can see a Lucent line here and a disruption in the cortex and with the high of faith. If we trace along here, we can see lucency here going right up to the top here. So we've got a fracture on the left side and it's intertrochanteric, as in, it's between the greater trochanter and the lesser trochanter. Um, so they have separated from the rest of the proximal femur. So thank you for everyone for contributing to that one. Move on to the next one. So this is the unfortunate victim of a of a high speed car accident. They have been ejected from the passenger seat of a car. A reasonable speed 30 40 miles an hour. Um, again, I'll wait for some answers to come through, but if you think about tracing those lines, this is quite a nice sort of hopefully not too subtle. Um, example. Mhm. So I'll just wait to get a couple of answers through Actually, a couple of findings on this one. Great. So we're starting to get a few answers through now a couple of people noticing different things, but there's different things. So what's interesting with this one is there are a few different things going on, but they all sort of come together. Um, so if we start with having a look at the sacroiliac joints, we can trace one nicely. Here on this side, it's a little bit less distinct. You just can't see it as well. And there's a bit of a Lucent line here. Lots of people in the answers in the comments have been suggesting a fracture of the island. I think that might be wise. There's this Lucent line here. I hope that's what people are saying. So certainly that is a fracture line there. Through the left iliac wing, we have a look at a bit lower down in the pelvis. It does all just look a little bit unusual. If we trace the pelvic brim, it's not at all matching up. You can see here that the pubic symphysis looks a little bit too wide. Look on this side. It's the center line, nice and intact. Over here on this side, it's all over the place, so something quite significant has happened. Um, what actually happened here is we've got fractures of the superior and inferior pubic Rami. Lots of people have suggested pubic Rami fractures so well done for for spotting either of those um, so fractures of both the superior and inferior pubic Rami and what actually happened here is what we call a vertical sheer injury. And this whole side of the left Hemi pelvis has been lifted relative to the to the right side. So they've fractured through the iliac wing and through the bottom of the pubic bone. And this left side of the pelvis has become completely mobile and has therefore lifted up. And we can see if we look at the level of the hips. The left femoral head is sitting a lot higher than the right femoral head. And that's because there's this looseness of the left side of the pelvis and they're completely detached. So this is something we call a mild agony fracture in radiology. You don't really need to remember the name just to remember that, um, that can happen in the pelvis. And as we said, because it's a ring, um, the pelvis often fractures in in two places, or sometimes more than two. Um, so to always when you see one fracture in one place like this one, look elsewhere and you may see disruption of the pelvis elsewhere, so that's great. lot of people have got various parts of that one. Right. Um, final case that I've got is this one. Um, So again, I'll wait for someone to come through. This is somebody who has had a fall from height. Um, see what you can see. Um, try to pick a non subtle example just to give everyone a bit of a hand both the way it projects on here. Uh, but we'll go through in a few minutes. I'll just wait for us to get some answers through. This would be one where looking at the joint spaces would be particularly helpful. Um, just looking through systematically, like we've talked about. So I think I'm starting to get a few answers. Um, there are looking pretty good. So lots of people are suggesting an open book fracture. Um, in case people are not quite sure what that means or what that constitute. Um, so the pelvis we talked about having it being a ring and having joints at the front and the back. So the sacroiliac joints at the back and the synthesis pubis at the front. Um, in various types of trauma, we can get significant widening or fracturing through those joints, causing the pelvis to open up like like a book. So if we have a look at the joint spaces on this one, synthesis, pubis is the most obvious thing on this image. Um, it's very, very wide, and we can't measure it on here. But if we measured, it would be a lot wider than five millimeters. Um, this is an indication of relatively severe trauma when it occurs in a traumatic injury. You can also get widening of the synthesis pubis in a wide number of pathologies, lots of rheumatological diseases and other bony, uh, soft tissue pathology. Collagen vascular disease is etcetera, Um, but in in a traumatic injury, it's a reasonable sign of of a high energy trauma. Also having a look at the sacroiliac joints. Um, it's quite difficult to convince you guys because I can't measure on on these images, but they do look quite wide and you can see both aspects of the joints on here, which on some of the previous images, we couldn't because in in an adult skeleton, they should be relatively well fused together. Same on this side. We can see a significant band of lucency so those joints are also widened. Uh huh. Tracing the other lines on the pelvis as we did before. Can't identify any other bony fractures. Um, so this is mainly due to widening at those joints. Lots of people got that one. Right, So that's great. Before I finish, I'll just go through some other bits. Um, using this one as an example of things to look for. Lots of people think about doing a pelvic X rays for things like steak role in injuries or coccygeal injuries. Um, coccygeal injuries are notoriously really difficult to look for on a pelvic radiograph, and we don't normally advise people to to do those, um, if if people have got real concerns about an injury to the coccyx, which is quite rare as they usually heal themselves. But sometimes we will perform a CT scan a limited CT scan of the pelvis to look for those things. But usually we we wouldn't do, um, Radiograph, for that is it's really poorly. Seen as you can see it, it's very indistinct here in the area of the coccyx, um, the sacrum. That is a little bit easier to see, and we do see, um, some fragility fractures quite commonly, and they will be horizontal. Faint lucency is through the sacrum. Um, these are the sacral Ala Are these little ovals here and they go all down. The sacrum should be 82 paired. So four paired sacral ala on either side so you can trace the symmetry of those as well to look for fractures. It can be quite indistinct as well, depending on how dense the organs and the pelvis are. But it's often worth a look. Um, and the other thing to look for in the pelvis, as we talked about with the abdomen, is soft tissues and gas as well. So soft tissues there aren't many that are very dense within the pelvis that you will see. Um, you may see densities from the ovaries or from the uterus, so things like calcified fibroids and calcified ovarian masses. You may see, um, And if you have major enlargement of some of the pelvic vessels, so with tumors, you may see soft tissue mass is arising from the pelvis, as we did in the previous example, Um, gas. If you do see it, it should mainly be in the central area, so that would be within the rectum and then rising a part of the rectum and the sigmoid colon, which again has the features we were talking about when you're looking at large bowel. So that's great. Um, so I think that is the majority of my slides. Uh, so just to say thanks, um, many. Thanks to Radio Pedia, it's also a really great resource. Radiologists use it all the time, but it's got some great, um, guides for medical students and junior doctors on all the different types of imaging. So, um, from chest X ray abdominal X ray through to the basics of looking at c ts um, it gives you some really good ideas and simple ways to look at things on the ward. It's also a really great sort of repository of information. So if you're ever unsure about words in the radiology report, or you want to find out a little bit more about how certain pathologies will look on imaging, it's got an excellent library of information and images to look at, and they allow the use of their images for teaching. And I've used many of those today. So many thanks to To the people at Radio Pedia. Uh, secondly, to Doctor Kevin Tank, who has arranged all of this and to everyone at mind, the bleep who've also given us the platform to provide some of these, uh, some webinars. So you might be feeling a little bit like this guy a little bit fried, but if anyone has any questions that they want to ask you, um, we can certainly open that up and and go through some Thanks, friend. That was You've talked to us all quite a lot this evening. You should all get feedback links email through to you right now. Just because I click the button. Um, that might go through now. I might go through the next couple of minutes. I've also just going to paste it all into the chat box now as well. Give me a quick second, so you should be able to see that too, in the check box. So once you fill in the feedback phone, you'll get the certificate sent straight to your email instantly. Um, so this Saturday morning at 11 o'clock in the morning, um, Doctor Henry double will be kicking off the start of the M S k bit of this series and he'll be starting with a structured approach, cases and pitfalls of hand and wrist X rays, which I'm sure we can all appreciate is one of the more difficult X rays as junior doctors to interpret. And then two weeks from now on Wednesday evening at eight PM, Dr Kang will be presenting an approach cases and pitfalls of lower limb M S K. So that will be covering knee, ankle and foot x ray interpretation. Um, so this MSK a section of the regular GI Series be quite useful, actually, especially if you're going to end up working on A and E because there's often no teaching about interpreting plain films. And then suddenly you start working on A and E, and then you suddenly expected to be able to know how to identify fractures, so this will be very useful. So the link to register for those webinars are in the chat box below. So don't forget to sign up for that so you don't miss out. And also the last link will take you to the mind the BLEEP website where you can sign up for all the webinars radiology and also the webinars for medicine surgery, urology. And there's a pediatric series which has started already as well. Um, I think there are some questions in the checkbox friend. Yeah. I'll just have a quick look. Uh huh. Right. So the first one I can see is, uh, somebody is asking about how to identify inflammatory bowel disease on on plain film. Um, so it can be quite difficult. Um, admittedly, um, to be fair, most. Most of it has looked at on CT these days. But some of the basic features, um, I'll see if I can go back in my slides to the or one sort of useful image that I have for that and just talk a little bit more about some of the features of that. Let's see if I can find it. Yeah, here we go. So, um, in terms of features within the bowel itself, um, the key one that we see is a Dema so fluid thickening in the bowel wall can be in the small or large bowel. Um, it gives thickening of the wall, which we can see quite clearly on this x ray, but it's not always very clearly seen. One of the secondary features of that is this thumb printing pattern, which is like the loss of the normal features of the bowel. So those how strong or the valve and the Combivent is, we don't see those so clearly, we see these sort of smooth and injury in regulations. Um, another feature that you can see is called lead piping. This is when the bowel just looks either a small bowel or large bowel piece that looks extremely smooth. You can't see any undulations in the wall at all. You can't see any of those how strong or valvular seventies. And that's to do with swelling of the bowel wall as well. Um, some of the features that you can see on plain film one of those, um, one of the main ones would be toxic megacolon. Unfortunately, I've got a picture of that, Um, but it does look like many of the cases that we've seen of large bowel obstruction. Um, so that's sort of an acute presentation of inflammatory bowel disease. Um, other things that you can sometimes see on a plain film are related to the inflammatory bowel disease. One would be free gas or pneumoperitoneum. If there's been a perforation of the bowel that has become so friable, um, other things you might see that are related a little bit more tenuously. We always in radiology when we suspect someone has got inflammatory bowel disease. Look at the sacroiliac joints. One of the main features that we see in the bones of patients with inflammatory bowel disease is fusion of the sacroiliac joints bilaterally, so you won't see those LUCENTS sees in the joints There they will be completely fused and other things that you might see on plain film. Patients with inflammatory bowel disease have got an increased risk of forming all bladder stones, so you might see some stones up in the region of the liver. And they are probably the main features that we see on plain film. A look at any more questions. I hope that gives you a little bit more information. Um, let's have a look. You can see somebody is asking to elaborate a little bit more regular sign. Uh, that's fine. I think it's a really, really difficult sign. Um, and yet we're all sort of taught it at medical school. But I think It's really hard to see. I'll see if I can go back to my image. I used to find it really confusing and a little bit sort of off putting. But when it comes down to it, it's actually quite simple, the principle behind it. So it's often called the double wall sign. And basically it's because we have gas on the inside of the bowel wall. And we also have gas because it's free within the abdomen, on the outside of the bowel wall. So the bowel wall looks different to how it normally should. We can see both the inside of the wall quite clearly and sharply and also the outside of the wall really clearly and sharply, Um, so the air is sort of outlining that here. I always found it really difficult to look at when I was in medical school and in foundation years. It's only really since doing radiology training, I'm a lot more confident with it. I would suggest if you want a little bit more experience with it, look up some images on Radio Pedia. They have a whole batch of images where you can look at different abdomen's that have got Regulus sign on them, and they can be really helpful just to start being able to sort of get your eye in tha What that should look like. I know it's a little bit vague, but one of the best things to do is to just look at it with lots of different times and lots of different images, because it's really hard, hard one to get. Um, I'll just see if there are any other questions, Uh, this one here about, um, looking at the difference between the value of the Combivent is and the house tra. So let me see if I can get one of the images up to help us. Let's try this one. So, um, again, it's really difficult when you've got dilated battle, but usually if you stick to the principal's, it can give you a lot of help. So the main thing with the house truck is that they're intermittent fold, and they don't go all the way across the bowel, so you will just see them like you do here in this really dilated large bowel. They're just poking into the center, these white lines. You don't see them on this side you can see another one here just poking into the center. So they are the house. Tra well, the economy entities classically look like this. They are white lines that go all the way across. Admittedly, it can be a little bit difficult when you have both small and large bowel obstruction. Um, I'll see if I can get my image with the case I had with that one, because they do start to overlap, and that can cause a bit of confusion. So this image has a large and small bowel. So what I tend to do when it's difficult to tell? Yes, I first look at the loops that are more peripheral in the abdomen. So, like this really big one around the edge and admittedly in this sort of region, it's very difficult to tell. But if you go down to the bottom of this loop, you can see those white lines just poking into the center and not going all the way across. They're nice and intermittent. Okay, more centrally again, Once the small bowel is overlaid on the large bowel, it can be really difficult. Um, and I admit on this image is it's also quite tricky. Um, but you can just see a hint of those lines coming all the way across. The best principal I find for looking at these roughly is just looking at the position of the bowel. So whether it's central, whether it's peripheral, how much it's dilated? Um uh, but yeah, um, there the main principles that I use, uh, see if there are any other questions. Um, I can't see anymore at the moment. So there's any last minute ones? Um, just pop them in the box. Um, otherwise, we'll start to wrap things up. Thanks, friend. That's great. One more minute. Just in case there's any last minute questions. That's fine. Um, so you don't forget to leave the feedback because that's exactly that's exactly how you get your certificate to show that you've attended this one and then don't forget to sign up for this Saturdays Morning on the hand and wrist X ray, because that should be really interesting as well. Let me see you next time We have a question. Could you please get back to the slide on the kidneys with multiple opacities in that condition, I can do. Yeah. So this is just an example of something that's fairly rarely seen on plain film. But it can be seen. Incidentally, it's not a reason that you would. It's not an indication for doing an abdominal plain film, but occasionally something you may see on one. Um, and it also just helps us to get an idea of where the kidneys are because they're very calcified on this image. So it gives us a nice image of those soft tissue kidneys here. So multiple opacities that would be consistent with nephrocalcinosis just calcification of the kidneys. There are a number of causes of that, um, and they differ on whether they are calcifications in the medulla or in the cortex of the kidneys. Um, these ones happen to be in the medulla, Which is the center. The central pelvic bit of the kidney. Um, and some differential for that would include things like hyper parathyroidism, medullary sponge, kidney renal, tubular acidosis. Uh huh. Cortical in Africa. All stenosis. Um, that would be, um, due to a range of things. So, uh, Hypo Hypothyroidism, um, and our ports syndrome. Many of these sort of congenital things can cause that, so it's something rarely seen But when you do see, it's quite useful to, uh, to not panic and to know what those calcifications are due to. They also give us a nice outline of the kidneys as an example. So I hope that's explain that one. Great. So I think we'll wrap it up there. So thanks again, friend. And well, thanks, everyone.