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Abdominal X-ray and CT Interpretation Session

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Summary

This on-demand teaching session presented by Jonathan Cretins, a Radiology Registrar in the East Midlands, provides medical professionals with the knowledge and insight on how to accurately read and evaluate abdominal X-rays and CT scans. Additionally, the session will cover the indications for an abdominal plain film, the normal and abnormal findings, the evaluation of tubes, lines, and foreign bodies, and will provide valuable information on how to detect and diagnose issues such as obstructions, absent psoas, retroperitoneal pathology, obstruction, perforation, and more. This knowledge is essential for medical professionals and the session will provide an easy to understand and helpful explanation on the various applications of an abdominal X-ray and CT.
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Learning objectives

1. Identify the indications of an abdominal plain film 2. Describe the differences between small and large bowel on a radiograph 3. Explain normal and abnormal findings on an abdominal radiograph 4. Identify the bones and structures included in an abdominal radiograph 5. Be able to recognize bladder stones, gallstones, and retroperitoneal pathology on an abdominal radiograph.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

so we can probably start the session now. So I will pass over to you on day, let you and shoot yourself. Thank you very much. Well, being everyone, my name's Jonathan cretins. I'm a radiology registrar working in the East Midland's. This evening, I'm gonna be presenting on the subject of abdominal X ray on up dot or CT. Um, I'm a, um sk subspecialty training, but CT, abdomen, abdomen electorate still forms a pretty big part of the on call duties. So I think it's a good topic to have Ah, well rounded knowledge off. I'm really working as a junior doctor or just transitioning to being a junior doctor. What I'm going to use is the chapped feature. So if any point anyone has a question, just pop it in there. I'll try and respondent assume as I can. Um, if, uh, okay with everyone, Okay. Eso the abdominal x ray. It's It's a commonly used investigation, particularly in surgery on it. So you. But its use has been declining over the past few years. Just with the improvements in technology off CT scanning the reduction in dose of CT on CT just becoming more frequently used open above X ray, however, it does give it still useful in providing clinical information. There's some specific situations which go through later on in the presentation. Some of the drawbacks off abdominal radiography that it does require much more radiation than a chest X ray. I just popped a few of the number's on there, so we measure radiation amongst other ways in millions. See butts. A chest X ray is about no 0.1, and you can see much higher nicely abdominal X ray on six. I understand the CT of your pelvis is anywhere between 10 and 20 so situations on abdominal plain film can be a smudge is half the radiation off a CT? So that's part of the reason why we're a little bit more tentative in the the way in which we use thumb. So traditionally, I don't know. You guys still taught this way of remembering the indications for an abdominal playing film, but we traditionally record them as gases, masses, bones and stones, masses and bones. You would never primarily order an abdominal plain films to look at, but gases and stones, or probably main ones, that it's particularly useful for um Also useful and not mentioned in that are the evaluation of tubes, lines and foreign bodies. You're probably all familiar with the requesting road. A graph. So look it and G tubes or NJ tubes. Medical drains things like that. Sometimes there's a small amount of free gas on on a radiograph, but if the patient has had a recent surgery, then that's likely to be normal. So when wouldn't be an indication on its own? Teo performer Plain film. More likely in the past, we'd monitor the passage of contrast Small bow ah, following three study. But CT is kind of overtaken that, and we wouldn't traditionally what we would typically use that as an indication. Nowadays, the big one is monitoring of really calculate, particularly in one of the hospitals I work in. It's used as a test just to see if the stone is is still in position or my have been passed because these are patients who are having multiple investigations and you wouldn't want to do a CT really tracks every single time they came in. They just do focused abdominal X ray to see if the stone is still there. Um, these are things that you will be very familiar with. But when you're reviewing a radiograph, you must check that you have the correct patient. You When the image was acquired on, if you weren't the one that requested, the radiographs is always useful. Just to check the indication why one of your colleagues has ordered the film check the projection. Usually it's gonna be always the same in abdominal radiographs. Occasionally they might be performed erect. But I personally haven't seen that as an indication a zar a method on many occasions. Um, the one thing that they can do if a just X ray erect wrist actually can't be performed is that they can do a lateral decubitus view can be used to look for freak ass. On this example of that, you'll be much more familiar with using erect chest X rays. Look for free I die from, But if the patient can't stand, we can do a lateral two Q tips and you can see here the rights, uh, levels of free gas, indicating that there's been a perforation somewhere in that. So the primary thing the house mentioned the beginning is gas. We look at the bowel gas pattern in abdominal radiographs. Small bowel, large bowel, small bowel. As you know, price. The absorption of the majority of fluid. The small bowel, mainly that option. Absorb nutrients. Usually there's minimal intraluminal gas. Um, when it's there, it's located within tight lips of small diameter. On the way we are able to differentiate between small and large. Bowel is the valvular a convent, a Z, which are new coastal falls which, importantly, stretch all the way across the small bowel loops. Contrast so that the large bowel, some of the free someone flu is is starting to be absorbed. So we get more material. We can get gas starting, develop on the loops are obliged diameter. Importantly, the mucosal folds that stretch across the Lumen only go part way across. And that's the main way. We used to differentiate between the two, so both of these are actually pathological examples off a radiograph, but they provide examples of what I was just mentioning. The house drop. You can see. Don't reverse the Lumen in the large bowel. In the small bowel, you can see the valvular they do traverse the Lumen. That's a good way of telling between the two So abnormal findings why we've actually requested the radiograph in the first place. Primarily violated leaves a small a large bowel likely examples off, primarily caused by obstruction by this or inflammation. You can also see a refloated levels on erect on. Um, I'm not gonna radiograph. Sorry. Know Iraq's I don't know. So, um, the quoted amount is more than five floor fluid levels greater than 2.5 centimeters. But in reality, if you see any levels, um, you should start thinking about what pathology might be underlying those changes. Another commonly reported abnormality is intraperitoneal gas resulting from a perforated discuss, maybe a Xarelto of of a tumor causing obstruction or a penetrating abdominal injury, uh, classically described as regular sign where you see gas on either side of the bowel. Lumen, which is pathognomonic off free gas within the abdomen, very minded that if the patient has had recent abdominal surgery, that may complicate matters cause that might be a small mouth gas, which is in there as a matter of normal course. Um, but having said all that, the sensitivity for detecting perforation is reasonably low on. I would recommend that if anyone suspects the patient has a perforated discuss, then proceeding Strip ct is probably the right course of action. Gas within the soft tissues is less common. On do is actually quite difficult to see on a radiograph is a nice thing to see if you do find it. But, um, I wouldn't worry too much about looking for free gas, particularly within the bowel wall, because sometimes the resolution of the radiographs is no suitable in order to see that. Okay, again, these are just two more examples off abnormal radiographs. Just the highlight. Multiple loops off dilated small bowel with the valvular. Yeah, on the rights. Lot of file obstruction, the house drink. Don't cross the Lumen. These the airfield levels that I was mentioning before in this one, we do have over five. So you'd be extremely concerned. There was a pathological process underlying this appearance. But even if you see one or two alarm bells should be ringing that a normal radiograph, maybe going to masses. So that's what this would only ever be unsettled. Finding you're never order an abdominal radiograph to look for intraabdominal malignancy. But it may be something that you find when you're looking for other things. So you need to look for the size and position off the liver, spleen, the kidneys and the bladder on D. Probably more importantly, is to look the outline of it. So it's muscle because any bulging or obliteration of the psoas could indicate a retroperitoneal pathology you might be looking at. So, uh, abscess resulting from a, uh, litis. Okay, dokey. I've just had one question. So the fluid levels here, you can see Can you see my mouth cuss? Uh, you see that perfectly level horizontal line here? There's no anatomical structures would cause that appearance. Um, okay, so there's been, um, taking hasn't a film because you can imagine if the patients lying flat on the fluid is going to collect within the Lumen on but not be able to be seen on the X ray. So this will be in a wreck film. There's fluid within the bowel, and it settled dependently. So with gravity, this this happens in established vial obstruction where the the integrity of the mucosa membranes off the bow, Um, is lost on fluid, starts to leak and collect within the small bowel lost bowel loops. Um, I was mentioning. So I shut It could indicate a lot of social oh can indicate a retroperitoneal pathology exam are so it's obsessive. A ruptured Triple A. These are two things you would never look for, primarily on plain film. But if you saw that, it would prompt you to move forward and request the CT after discussion with the relevant surgical department. Much with much as with this bones is another thing that much better with dedicated image ing such a slumber spine X ray Pelvic X ray. Mm, an MRI spine. If you're looking for a cord compression, but because they're included on the image, you must interrogate them just to make sure there's no inside. So finding or or something which may be causing symptoms that you weren't expecting. So the bones to interrogate ropes, lumber, spine, sacred six poetess And sometimes you get the proximal femur as well. If the patients got on the femur fracture and it's just about visible on the X ray, it would be really important to pick up on it. So this is just a pictorial representation, which I've taken from Radio Pedia, the outline of the liver and spleen. No very well discerned or radiograph. But important to note this is the I have a lot of the service muscle that I was mentioning and he said, outline could indicate the rest of the parents nail pathology. The course of the urethra you can see goes over the spinous processes over the sacroiliac joint dips into the pelvis out such a pawn that later. So just remember the course that that's takes. And then we got all the bones I was mentioning before, Um, this is basically the same diagram, but just highlighted with markers. So the last thing we're looking for his stones and this is actually one of the things that it's more useful for looking at with cereal imaging. Look for really stones. You're a pterygium bladder stones, as we mentioned before, trace of course, course of the ureter as it comes down from the renal pelvis over the spinous over the transverse processes over the S I J. And then down into the bladder, most really statements. You gonna pick up on them plain film, but opposite from that in the right upper quadrant, if you're looking to see Gold Stones and that's a bonus. But most of those, um, you're not going to see just example off. I'll just highlight here, that kind of thing that we're looking for. Your retract stone. It's in the mid ureter. As we mentioned, the ureter traces down over the transversus processes. So this is lying about l 543. Um, this is approximately that route. The ureter takes on just a highlight. This stone there. At first glance, this might appear like a normal radiograph Exume in and pay more attention to the right upper quadrant. You can see that there are multiple, well defined calcified course, So this would be a nice pick up personally if you ordered the radiographic weren't expecting to find the patient had gallstones. It could be the cause of that abdominal pain. They might have biliary colic. Um, do you mind? I've been expecting to find those these obvious examples of stones, but other things that we look for in ingested foreign bodies. This was a patient who had ingested multiple I sense of cutlery, handles batteries and several of the, um, hot item. Uh huh. On on the on the right hand side. Here. This is a person who didn't ingested multiple, um, little pellets, both, um, bound substances important to identify those. They're likely this point to be within the stomach on. Therefore, they likely to be retrievable endoscopically. However, once they pass into the small bowel and beyond, it's not going to require an operation to get them out. Uh huh. We'll just have to wait until they pass out naturally. So I would say a small bowel obstruction was traditionally the most common reason that people ordered abdominal radiographs. It's the vast majority of mechanical bowel obstruction on does have a reasonably high mortality attached to it. Etiology is either congenital requires come genital being much less common, um, usually presenting with in childhood. So these patients usually have a history of a known congenital abnormality. I'm particularly trees here or previous middle of all this ankle diverticular may present later on, essentially in adult on it also might be found was an incidental finding. In Collin CT. The acquired causes a small bowel. Obstruction is a much more common on within the category. Adhesions would be the most common cause and most likely to occur to the patient's heart. Abdominal surgery. Um, so you get people who have had previous cancer sections coming back with small bowel obstruction. Honey is also reasonably common. The intrinsic causes, such as information of the bowel wall, ischemia or schumer a less common, particularly small well, tumors are, um, but missing the rare, but it's still something about your mind. And, like we just saw, ingested foreign bodies, particularly there of the size of cutlery of batteries. They can easily include the small bowel. So when looking at the abdomen paragraph to interrogate for a small bowel, obstruction is important to remember that roughly only 50% sensitive, Um, because if the bowel is full with fluid, if there's a chronic obstruction on, the small bowel was filled up with fluid. You might actually be able to discern the individual loops. It might be completely featureless. That's what you need to rely on your clinical findings if the patient is vomiting. But there's no open their bowels. Even if they have a normal appearing abdominal radiograph, they could still have small bowel obstruction. If we do have signs, we're gonna be looking for dilated proximal loops. They're predominantly central. Just because of the anatomy of the large bowel is usually preferably located in the abdomen. Well, see the valvular like we saw examples on before. On If there's if they've had an erect study that we might see, there's a lot of fluid levels. Um, I put you have no steam. A radiograph performed us on Iraq study, so I wouldn't worry too much. If you're not seeing affluent levels, it's most likely that it's been formed supine on. Therefore, you're going to see the levels on those studies. So this's an example of a florid small bowel obstruction. You've got multiple loops of small bowel, the quoted goes off signs. Four small bowel, large bowel and seek him, traditionally three centimeters. Six. It was a nine centimeters. I haven't got a measurement on here, but these are weigh over three centimeters, which would be considered normal, but it's quite obvious this person has an abnormal small bowel. But what you have also have to consider is the other things on the radiograph. These little metallic items in the right eye that foster likely to be surgical device used for holding a mash repair in situ so the patient previously had a repaired. It may be the case that the repair has fails on the hernia is represented. Also, we know they've had intraabdominal surgery, so they're more likely to have adhesions which have formed. And they may be the reason that the patient has got a small bowel obstruction. So interrogate the bottle. But also look it. And you're the surgical devices, which might be so. There's these things in the right lower quadrant, which a little, uh, which are a device that the surgeon uses in Got big surgery. Too bad here, the mesh onto the abdominal wall to stop the the hernia getting through. Then we've also got staples on the right side, but the right side of the image, the actual left side of the patient. So this patient essentially has had it also on top of this small on top of the hernia repair. They may have also had a bowel resection, which would be another reason for them to develop a small bowel obstruction. The 369 refers to normal measurements of the bowel in centimeters, three for the small bowel, six for the large bowel and nine for the cecum. The cecum is allowed to be bigger than the large bowel, so those that there no absolute values. But if the small bowel large bowel will see it come a bigger than those in centimeters, then you can definitely say this pathologically dilated. And I just a rough cut off. But you can still like to mention before you can still have bowel that is less than that and still be pathological. So large bowel obstruction much less likely than small, only around 20%. And the most common course that I see is, uh, large bowel malignancy, which in itself is much more common in small while and typically located in the sigmoid. Also intrinsic abnormalities of about war. Such a diverticulitis, um recurrent volvulus is something we see quite a less off in the elderly population, particularly in patients who are not fit to have a big operation to receptor the abnormal bowel. They have recurrent volvulus on typically sigmoid or sequel signal. It is much more common. Um then see, I'll just show you both, so only radiograph we're looking for Kalanick distention. The distal colon is collapsed. Nothing get through the obstruction and also dependent upon the Eylea sequel valve. You may have associative small while obstruction, which is actually better for the patient. If the artery is equal, valve is competent. You can get back through the large bottle dilates. Um it is more likely to rupture because the pressure can go back into the small bowel. Um, but that's not something you can do terminal on radiograph the competency of the ideas equal. So this is an example of a large bowel obstruction. You can see the house for markings abnormal diameter. So competency of the either sequel valve. If you have a large bowel obstruction on the small bowel obstruction, reasonably assume that the valve is incompetent. However, for a definitive answer, you would need to, um, request a CT abdomen on day one. There's a large bowel obstruction. The radiologist will always comments on constant competency of the valve because a competent valve is an indication to the surgeon that they would need to potentially intervene clean because the large meals at a greater risk of perforation. This is another example. Just have a large bowel obstruction. This part of this vial even more dilated, definitely over six centimeters. We've got no gas in the rectum. Incidentally, we've got, uh, um uh, head replacement. I'm just another indication of that kind of age of the patients that we're seeing with these pathologies. So, like I mentioned before, there's two types of volvulus sequel or Sick Boy. This is an example of a sequel, volvulus. Traditionally the teaching is that they point towards the left upper quadrant originating in the right. I'll act faster, which were the cecum is located. Um, the hamstring markings are typically more well, delineate exit in, opposed to a signal involving this which arises in the left eyelid. Foster points up towards the right inside here we can see we've lost completely lost the hospital markings. Mrs. Traditionally brought This is an example of the what would be the coffee bean sign off? Um, signal involving this. So from printing is ah, term used to describe a sign off large bowel wall thickening, which is, uh huh. A Dema is infiltrated into the house drawn markings and they become thickened. We can see this in typically seen in inflammatory bowel disease, pseudomembranous colitis. It can also be as a result of ischemic bowel rarely and diverticulitis. Although typically the patient would probably undergo a CT scan before bowel becomes that inflamed so you can see as compared to the previous radiographs, where the house remarking Zwart clearly delineated here you can see that much more thickened, which is, Ah, evidence of this person's colon is quite unhappy here. The house for markings have been completely lost, with more fluid on a demon within the within the large bowel wall, Further evidence that it's grossly inflamed. Okay, um, Leslie new repair. It's name or free gas within the intraabdominal cavity, which is typically resulted from perforation of a hollow viscous. Uh huh. So the fluid is actually within the wall of the bowel? A disappointing the fluid hasn't progressed to being within the loop itself. The reason we've lost the house remarking because the bowel wall is a dermatitis, a stage that fluid hasn't actually leaked into the Lumen of the large bowel. Yeah, so this is just within the Lumen. The actual you wouldn't necessarily describe this bowel wall is dilated. It's still probably within 45 centimeters. But it's more that the striking feature is that the house remarking that completely lost the three signs that we typically look for off a pneumoperitoneum only I don't know radiograph, a regular sign, which I mentioned before, where you're getting on either side of the bowel wall football sign on false, a formal, even sign. I'll show you some examples of those. This is a pediatric radiograph, but in fact there's so much free gas within the abdomen that the border, the outline of the abdominal cavity, his outline and this is set to resemble a football. Here. We've got fancy form ligament out over the midline by large volume of free gas within the abdomen. Um, so, in summary, the abdominal radiograph is becoming less used. Jesus improvements in CT technology. But like we mentioned, particularly for, um, follow up off renal tract stones, it does still have its uses. It's a quick, easy and jeep performed test. Sometimes CT might not always be available. I'm usually, and abdominal radiograph could be performed at any hour of the day on. You need to be familiar with the common pathology, but also the incidental findings like I mentioned, whether it be Goldstone's or whether it be a surgical device, which might pointing to the underlying etiology of the abnormality. Increasingly, patients who tend the emergency department or president award on there acutely unwell, it's a likely to proceed directly to the CT surgeons or increasing unlikely to want to operate on a patient with only X ray findings, which is completely understandable when when you're in a, um, life to teaching hospital when CT is available. 24 7. When the skin convert performed within the matter of minutes, the surgeons need to know exactly what they're gonna be operating on. So that's a reason why the radiograph is falling out of fashion. But if there's ever any uncertainty, if you have a radiograph, which you're unsure about, it may be different across very centers. But where I am in these Midland's, there's a number to ring and there's a radio is you register all double, uh, 24 hours a day. We've got diagnostic monitors on Dawei that our system is set up. We have easy access to all the patient's previous imaging on the previous reports attached to those images. So if if there's any doubt you can just give us a ring and we'll be happy to discuss the findings with you. So that was a useful somebody summary of the abdominal radiograph. Um, more increasingly more popular CT for computer tomography, which I'll talk about for the second half off the talk again. If there's any questions, just pop them in the chat hair on. Hopefully, I'm able to respond to those in June course, so the actual physical or scientific basis off the CT is the same as X ray. The variable density of the organs allows us for easy identification on determination of pathology. Um, the CT is acquired volumetric manner so that we're able to reconstruct the images. You probably reviewed patient CT scans on the wars or in teaching, and usually they're sent to you with axial, sagittal and corona reformats. You're able to look at structures from multiple different views, and it also allows you to measure accurately on monitor the progression of any disease process. That's particularly useful in cancer, where increasing size of tumor is one of the most important things that we measure in terms of determining whether patients responding Teo therapy alone, we have multiple detectors on spiral scanning which essentially weakened means which perform the scan in a matter of seconds or a couple of minutes. So almost a fast was a radiograph, but much more quick, much quicker to perform that MRI scan or an ultrasound scan, for example. But we also have the ability to at the same time give the patient intravenous contrast, which is typically and I donated. Contrast on. The basic principle behind is that it's very dense medium, so that any structure it makes its way into um is much more evident on the scan in comparison to the soft tissues or the fact or something which hasn't taken the contrast. So more specifically, abdominal seating. It's widely used across the hospital, particularly an emergency department inpatient and outpatient setting anecdotally to me, and my practice is probably the second most common. The request it's gone on know prizes for guessing that the most commonly requested scan is the CT head, which I think in this point is almost mandatory for anyone attending the emergency department that includes the relatives. Like I mentioned, such as CT, can you pay drama scan, Multiphase gunning and malignancy scans? As you mentioned at the very top of the presentation, the average radiation dose is actually not much higher on play film. Um, the caveat to that is patients increasing in patients with a high B m I may receive a much higher dose of radiation. The way in which the CT scan of works is that the dose is automatically adjusted. So if it's having to get through a greater amount of tissue, such as with the patient hae am, I will increase the dose in order to provide a diagnostic picture. Say, if you have a patient Um, uh huh. I'll just under this question. So no, only the only contrast that we use for CT scan delivered intravenously would be isolated. Contrast. They're particular indications where you might give a patient or, a contrast, such a zit. You're looking for a gastric. I suffer GL perforation, but typically, if you order a CT abdomen, pelvis with contrast, what will receive is I'd nated intravenous contrast. That's the routine, the routine, um, scum. But unlike the abdominal radiograph, there additional factors to consider um, renal function pathology. What you're actually looking for phase of contrast, which I'll go through in a few minutes on where the patient has had any recent surgical procedures. These are all relevant. The request that you make, and even though I've said abdominal see, he is much more frequently use and is widely used. There are still other scanning modalities, which may be more suitable, and I'll discuss in a little bit of time some occasions where you might want to request an ultrasound, MRI or a nuclear medicine scan. So this is a snapshot off the different types of indications. I'm sure you'll be aware of most of these on do predominantly in the emergency department. Abdominal pain is that primary indication, but it's also the workhorse for primary or secondary malignancy. With abdominal metastasis, you may be looking for a pyrexia of unknown origin. You may consult with the microbiologists horrible to Destin. You do an abdominal CT to see if there's an underlying infection where you might be looking for a postoperative collection, which is another commonly used indication. Bowel obstruction, like we mentioned before, much more sensitive than the abdominal radiograph or mesenteric ischemia, which is common in elderly patients who have vasculopathy. Maybe they've got peripheral arterial. He's that likely to also have disease intraabdominal vessels. G. I bleed off put acute in bold because in order for the scan to be most sensitive, patient really does need to be bleeding at the time of scan. Um, a trauma scan which typically, in our center at least involves a CT head CT, cervical spine, CT chest on the CT abdomen. Uh huh. Postoperative follow up is less common, but there are some cancers which do require so six monthly follow up or something like that. And I'm not physically with radiographs like man particularly sensitive. There's some pathologies. So CT would be the natural progression. Uncertainty on planning for surgical procedures? Probably the most, the the last, most commonly used indication. So this is the four most common phases of scan on. You probably be familiar with contacting the radiologist on them, asking you which phase of scan you want the patient to be scanned it. So it's useful to just have a brief overview of what we actually mean. When we ask you that question, um, so a noncontrast CT. You might see abbreviated toe N c E C T. If you're familiar with that, a CT k u B but for renal stones is non contrast. If the patient has poor renal function untolerate, it's the intravenous contrast which can cause they're real function to deteriorate. I know the common reason is If the patient is undergoing hemodialysis, maybe they have chronic kidney disease. Maybe they have a sepsis with an a k I. So always important to check the renal function before question is, Can tracking a foreign bodies? We wouldn't typically do this with CT, but in pediatric patients if they swallowed, for example, of battery. And there's, ah, time limited. Um, it's time living Sit Course. The surgeon needs to know exactly where the battery is, so you can take it out before potentially erodes into the bowel wall will perform a noncontrast CT. All we need is the anatomic information. We don't need to see any organ in particular. And, of course, if the patient is allergic to contrast, we were performing on contrast CT. So portal venous face is kind of the standard update. POTUS. If you just request on your system CT, abdomen, pelvis. This is the one which will be performed as a default. As a general rule, it provides the greatest sensitivity on specificity for the widest net potential pathologies. So if you if you think your patient has a cancer on, they may have perforated the ball. They get a portal venous phase if you think they have an intra abdominal infection of some kind If they have a post surgical collection, this is what will be performed face. Um, we perform this gown much sooner after the contrast is administrated, which makes sense a zit going to be in the on trees before it gets back into the veins. In particular, hypervascular lesions most commonly would be her Paterson of the carcinoma. But in the emergency setting would be looking for a triple A potentially rupture Triple A or mesenteric ischemia, Ischemia in the more elderly population with underground underlying arterial disease. Um, triple face. Come if you've heard the time you and not been exactly sure what components go into that if we're looking for an acute terribly from. So, yeah, the 22nd delay is when the contrast is going to be still lying within me intraabdominal arterial system. So it has to go into the arteries, and then it comes back into the venous system. So the shorter delay, the more likely it's going to be in a, uh within the arteries. And I'll give you, um, picked oral representation in a little light list of why that's relevant the triple face scan in acute job lead is the most common indication on That's the non contrast. Well, the Venus and the arterial face. So we do the non contrast scan to look for anything which might muddy the water. A. Such if the patient has intraabdominal calcification. You don't want to confuse that for an acute hemorrhage, which would also with the contrast show up is very dense appearance so we can rule out those with the non contrast phase. Next is the arterial face on. You might have heard the term blush, so we can usually see a little blushing. Oh, fast, which we used to discuss the bleeding point, then potentially refer the patient on to interventional radiology. You can, um, potentially include that vessel and stop the bleeding. And then the venous base gives us an idea as to the volume of blood because there's a almost a minute delay between the two. We can determine the extent of hemorrhagic pulling on, or C, where the hemorrhage is troubles along the bowel, trying to turn the volume of blood which is being lost. So this is the this is an example of a noncontrast scam you can see compared to the abdominal radio. If we're still getting good anatomic detail, clearly see the margins of the liver. Kidneys explain, but there isn't a great amount of detail hum over on the right inside here. What is good for is determining real truck calculi. You can see the stone is extremely dense, most appears same. Density is the partially imaged pelvis that we've got here, both sides. So it's This is a great scan to look for renal stones. You can see the stone is in the right ureter and upstream of that, we've got the right kidney, which, when compared to the left, is quite abnormal. The book stuff surrounding the kidney is the most enteric fat, and you can see that it's not clean and crisp like on the left hand side. So they suggested, suggests that the right kidney, um, my progress to a pilot Porisis as a result of an ascending urine tract infection caused by the urinary tract stone much greater detail than you would find on abdominal radio. This is an example of the portal venous face. Over here on the right hand side, we've got the portal, that which you can see nicely, Um, which you weren't able to see on the plane. Scalp. Also, you can see that they're different organs take up the contrast of different rates. So the kidneys taken up along the bluff, The contrast, it appears slightly darker. Then on the right hand side, where we see the liver, you can see some of the liver vessels. You can see the vena cava and then over on the left. Here, we've got the large bowel, which, you can see is nicely highlighted against the intraabdominal fat. And as an example of a pathology in the large bowel, we can see the sigmoid colon. Okay, on this is to is a Corona image. We're looking face on it. The patient. This is an actual image, the bowel here about Wallace thinking there's haziness of the mesenteric fat like we discussed before. And this is an example of a sigmoid diverticular itis. And finally, we've got the arterial face you can see in comparison to the portal venous face, which I'll just flipped back to the aorta on they see their access access as much brighter. So the contrast is still within the abdominal aorta. It's perfect for seeing vessels and any pathology that might be related to the vessels A little bit further down the patient. You can see this vessel here, one of the highly a college arteries as a central filling defect. Um, we would be unlikely to see this on a portal. Venous factors, because the contrast would have passed back. It's the portal vein, but hey, you can see is a nice thrombus, indicating the patient is likely suffering from mesenteric ischemia as a result of reduction in the arterial flow to the bowel. So this is just a slide, too. Help you guys get your CT scanned in a timely fashion so that there's no delay under the patient. It gets the right imaging. How the right time. So you want to get the best scan? Few patients. I don't know how familiar you are with working the motions department, but we quite often received request. That's just, say, rule out obstruction or perforation. There's often no additional clinical information attached to that, and for us, it's quite difficult to know this doesn't really I want. The underlying etiology is, um, are they looking for on obstructing cancer as the patient previously had surgery on my half adhesional obstruction. Is the patient septic or systemically unwell? Might they have an intra abdominal infection? So the best thing to do is just give us much clinical information that you can. And as I've gone over before, the different phases of scan. If you provide us with all the information, that means we can choose the phase of sound on the coverage. That's going a lot. I used to get your diagnosis for the patient as soon as possible. I'm trying to cut down on immunity kind of associate it, and tied in with that is appropriate by market biochemical markers. Have your patient has a CRP of three hundred's? Then let us know because we'll we won't ask anymore questions, and we'll get it done as soon as possible. Um, on the flip side of that, if the patient is so one, well that their lab hasn't had time to process the blood results. Also let us know because we don't want to delay a scan in a patient who's critically on. Well, if they are, we'll do that usually with contrast without knowing the the, uh, the real functional of the markers because that could lead to the patient having life saving surgery without having to wait for the blood results to come through. One of the most important things is to just give a brief overview, very surgical into contention the patient might of hot number one. If that was recent, then they're gonna have some gas within the abdomen. And we don't want to tell you that your patients got a perforation when in fact, they just how the love frosted me three days ago on. But some gas in the abdomen is normal, but with patients living longer and having multiple complex surgeries, if you could give a brief overview of what surgery they've actually had, we can spend less time trying to work out which better bowel they've had resected or what off the liver they've had receptive, and we can try and get to the diagnosis quicker. And also, if the primary diagnosis is unclear, if a differential diagnosis, if that can be provided, then we can potentially tail of the scan to cast a wide and nets and maybe pick up on things which may not be immediately obvious. We can add in additional phase of scan. Um, so just let us know. Onda have to be telling you how wonderful CT scan and Hung worm. It's amazingly sensitive and specific. There are pathologies on D structures, which are not always best looked at on CT on D. In those, we could potentially use a different modality or rely on a clinical diagnosis. So some pathology is not well demonstrated on CT or gall stones or colecystitis, particularly in the chest of the moment. People aren't having their color cystectomies, and so they're going to be having recurrent bouts of cholecystitis. If that's a young patient, we want to avoid a repeat CT scan every few months because we probably know they already have gallstones. They're probably going to have inflammatory markers, which a typical off color cystitis. So we can probably get away with just doing annulled sound to confirm the diagnosis without having to to repeat the CT Um, in a similar vein. Acute pilot arthritis. If you're not suspecting any complications, CT is actually relatively insensitive to the changes in the kidney during the acute phase on what we want to avoid is telling you that there's no radiological evidence of pyelonephritis on potentially building in a delay for the patient getting the antibiotics or appropriate treatment. So if you suspect to keep pilot writers, it's probably better to go ahead and treat him for it instead of relying on the CT. Um, some structures aren't well demonstrated on CT, and this is particularly the case for gynecological. It's particularly the dress on dexa structures is because of the anatomic makeup of the uterus on the pathology is which afflict it. We can't provide a sensitive, what specific diagnosis on CT, and we would suggest that trans vaginal ultrasound would be more appropriate if the patient's stable and can have an ultrasound scan. If there acutely and well with raising phlegm, a tree in markers and you you're suspecting maybe pelvic inflammatory inflammatory disease or a tube oh, very obsessed them. We could certainly consider CT. In that scenario, ruptured ovarian cyst is another thing that we would be reticent to scan for. It's perfectly normal for a a young woman off childbearing age to have a small amount of free fluid within the pelvis. So if we scan her and see a small amount of fluid, there's really no way of telling whether that's a ruptured cyst or whether just is normal part of fizzle physiology for that For that patient, Um, and there are some things in which clinical diagnosis is regarded is being sufficient on not requiring the CT diagnosis. The most common is acute pancreatitis. There are three criteria for diagnosing it, which is typical right? Typical epigastric symptoms elevated, UM, a laser light base on D findings on CT. But if the patient has two of those, it may not be necessary to progress to a CT, and it's in a similar vein to patient with Coexist itis. These patients, they're gonna have a recurrent scans. They might develop chronic pancreatitis. And so we want to avoid repeat scanning. Um, allergy patients with recurrent volvulus is one of those incidences where an abdominal plain film is probably sufficient because they're likely to be on Victor's surgery anyway. Appendicitis used to be a diagnosis which didn't require CT, but now, particularly in our hospital, we have a protocol for scanning patients with a low dose contrast enhanced CT. So we still give them intravenous contrast. But the the sequence is has been tweaked. So is to give a lower dose. So if you're reasonably happy that it's appendicitis, you're not too worried about the other intraabdominal structures. We can do a low dose contrast, enhanced CT, which is gonna give us a pretty good idea of where they have a dentist or not. And then you can progress to contacting surgeon. So a brief abdomen a brief summary on CT abdomen. It's a highly sensitive, specific test, formal sports drop down, or pathologies, which I've tried to go over during the second heart for the presentation. But we must consider the radiation burden, particularly young patients, on those requiring repeat scanning even more so now with the, um, cove it pandemic, I'm sure on that. Entex Resources We're getting a large volume scan requests. So if you provide good differential diagnosis andan accurate request, it means that your scan for your patient is most likely to get done sooner, and then the patient can have the appropriate treatment on hopefully be discharged soon. That would be a little, and like I was mentioning before, it may be different in your hospital, but in mind, if you have any doubts or simply need advice, there should be a radiology registrar available today. So if you just give us a ring, would be happy to go through any Requip is. I would ask that you don't call us it three AM to book outpatient scans, but anything else during would be happy to talk to you. And that's my brief teaching on CD Abdomen X ray on DCT. So if you have any questions, I'll be happy to. It's There's anything that you're, um I mean certainly provide a copy of the slides. I think I'll I'll do that through, um, the chapter. It's moderating. Sure. He's able to provide you with this life certain? Yes. So, in terms off the slides of you share them with me, I can. Then I'll put them on the Facebook group on the Facebook event, and I'll send everyone a link viremia else they can access them. There is about, um, no problem. Brilliant. Thank you. Recession tonight. No. Putting the feedback link in the chat for everyone to complete. Now compress the feedback back over to you. Um, and if you complete that, I think would give you a certificate as well. Yes. Sorry. Yeah. No, I really appreciate if you guys could give me feedback with the finding a pandemic and everything it's doing. Online teaching is becoming more common. So any feedback, how I can improve in future, um, it's really welcomed and whether it's a positive, constructive I'm happy to receive a lot of feedback, said I'd be perfect if you could. Are there any further questions? So the recording for the previous sessions you can find them all on our Facebook page. If you go look in the events, um, you can find them in there. If you're struggling to find them, I will leave our email in the chat as well. And if you send me an email, I can give you the links that you need. Okay, so if if there's no no questions, then I'll, um, I'll end the presentation there. Thank you all for Thank you for joining on a Sunday evening. I know it's not the ideal time, but I appreciate everyone looking in on, uh, watching the presentation. Thank you. Brilliant. Thank you very much. Thank you.