Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Um I'm the, I'm the first year radiology resident at Imperial. Um And so hopefully, this talk is just gonna be like a brief tutorial about how to approach the abdominal X ray. Um Hopefully, like by the end of this, you'll have like a systematic approach on how to approach it. Um So before we get into the actual approach, um I just wanna point out a bit of the anatomy that you should be familiar with um on an abdominal X ray. Um So a few things that you can group, so they have to identify um basically bones, um soft tissue and gas or air, let's say, um starting with the bones you can see down below we have the pelvic bones. So we have, so before I just um go on, I just wanna make sure that you guys are aware when you're looking at an X ray, um you're looking at the patient facing you. So this side is the right side and this side is the left side. Um So this is the right iliac bone or right ileum. This is the left iliac bone. Sometimes you may be able to see a bit of the pubic bones as well down below and a bit of the femoral uh bones. But in this case, we just got, um, mostly the iliac bones and a bit of the spi pu pubic remi on both sides. Um, you can see as well. We have the lower end of the thoracic spine. We've got the lumbar spine, the sacrum and a bit of the coccyx at the end. And you should, um, be able to um number the uh ss the vertebrae, the easiest way um is to just go from down below. So, if you know that this is your sacrum and this will be S one and the vertebra above, it will be L5 and then you go upwards, L4 L3 L2 L1 or you can find the fi final rib. Um So in this case, this is rib T 12. This is the left one. This is the right one. And this way, you know that this is T 12 and you can also number the vertebra below or above. Um Like we, as I mentioned, uh other bones to be uh familiar with are the ribs. Um So in an abdominal X ray, you'll see the lower, let's say 4 to 3 ribs. So on this side, you've got rib right 12, uh rib, 12, uh the right 11th rib and the right 10th rib, just the lateral aspect of it and the same on the other side So now we're kind of done with the bones, um soft tissues you should be aware of. Um The first one is the liver, liver, which occupies your right upper quadrant. On the other side, you've got your spleen, the left upper quadrant and in the kind of center of the abdomen, um parallel to the vertebrae from T 12 to L3, you've got the shadows of the kidneys on both sides. Um Sometimes if the, if the ureters are dis, they've got some disease or dilation or even contrast, you may be able to follow them as they course over the transverse processes going all the way down to the pelvis. Um of course, overlying the psoas muscles, muscle shadows. Um Another soft tissue that you should be able to localize are the psoas major muscle shadows on both sides of the vertebrae. And as you guys know, they originate from L1 and insert into the lesser trochanter. Um So this is the area where you'd expect to see the psoas muscle, ok, on both sides of the spine. Um ano one final soft tissue that you may sometimes see is the shadow of the urinary bladder in the pelvis. Uh Finally, we talked about uh gas or air which you will be um able to visualize in the small and large bowel. So it's normal to have a few visible bowel, small bowel loops in the pelvis and also normal to see a bit of gas in the large bowel peripherally. Um, but we'll, we'll talk about the cut offs, let's say of the diameters, uh, for what is normal and what is abnormal. Um, but it is normal to see a bit of gas in the large and small bowels. Um, but we'll get on to the pathology later on. Um, if there's, um, any questions, um, if the moderator can please point them out or pause me if you want. Um Cos I can't really see the chat when I'm on my window. Um So again, this slide just kind of highlights the soft tissues, the bones that we talked about. Um and the kind of the gas that we talked about as well. Um And the spine, there's a few more details that you can also visualize. Um So, as you guys know that this part of the vertebrae is the body, um centrally, you've got the spinus processes and on both sides. Um going laterally, you've got the transverse processes. Um This kind of oval shaped hyperdense, the central hyperdense area um are the s are the sides of the pedicles um which you should be able to localize as well. And if they are absent, if one is absent, uh then it may indicate disease, like for example, uh metastases or fracture, et cetera. Um So, yeah, I'm not gonna go over again o over the soft tissues and bones that I've pointed out. But you should, you should know the normal in order to interpret it uh A X ray. And this is again, just a picture with all the landmarks I talked about and the numbering that we talked about as well. So systematic approach to the abdominal x-ray is has a pneumonic which is ABDO X. Um So a stands for air. Um And basically, this refers to you knowing what is abnormal air. Um basically air that's outside, the bowel air should only be visualized inside bowel small or large, but it should not be visualized outside the bowel. Um B is looking at the bowel pattern. Is it dilated? Um Is it shifted? Um Other signs that we'll talk about in a bit D stands for densities and calcifications. And o refers to organs and soft tissues that we talked about earlier and some pathologies that you may be able to recognize and X is the external objects, lines and tubes. So we'll start with air A for air. Um Like I said, air should only be seen within the lumen of the bowel and you have to be familiar with some abnormal um extra bowel air um signs the first one. I think everyone has seen this or read about it. Um So on a chest X ray or on an abdominal x-ray gas underneath the left hemidiaphragm is normal because that is where the stomach bubble is, however, gas underneath the left hemi uh sorry, the right hemidiaphragm is always abnormal and it represents some sort of free intraabdominal air. Of course, depending on the clinical context that this can be, let's say expected or it can be um pathological. So if someone has recently had a laparoscopic surgery or even ao open abdominal surgery and they had this abdominal X ray, it is normal to have some air beneath the right handed diaphragm, post abdominal surgery. But if someone is coming to A&E um, he's got severe abdominal pain, they're tender guarding, they're rigid and they've got this free uh air underneath the right hemidiaphragm, then this indicates a perforated viscous. Um So air under the right hemidiaphragm is what we call a pneumoperitoneum and refers to bowel perforation. Um Like I said, you should always correlate with the clinical history. Ideally, um patients should be standing up when they have an abdominal X ray because that way, according to what is less dense, which is air will go up and will be easier to visualize if the patient was sine and they had um free, free infraperitoneal air, it will be difficult to see it because it will go up according to what is less dense or we will track down and still be a bit more difficult to see. So, ideally, you should have your patient standing up for the abdominal X ray if she's suspecting some sort of preparation. Um Another sign um of free intraperitoneal, there is the falciform ligament sign. Um So from anatomy you guys know that the falciform ligament is uh kind of a peritoneal, a peritoneal reflection which extends from the um anterior surface of l of the liver towards the anterior abdominal wall and it separates the right and the left lower lobes. Um Normally you shouldn't really see it. Um You may be able to see it on the CT. Um but if you've got a perforation with free air kind of traveling inside the abdomen and this air will go on either side of the pals form ligament. And basically, it creates like a contrast um window for us. So if you look at the X ray, um you can see the falciform ligament is very well visualized. And in this case, uh you can see it because there's air on both sides which is dark while the fosfor ligament is soft tissue, it's dense. So you see it as a bright line and this is abnormal indicates free interpersonal air. So this is the second sign of a pneumoperitoneum. Uh Another sign that you guys have to be aware of when it comes to free intraperitoneal air is the regular sign um or it has another name uh a double war sign. Um So normally you shouldn't really be able to define um the walls um of the bowel on either side. It one should be kind of vague. You shouldn't be able to, to like delineate it clearly. But if you've got um air uh free in the intra cavity and air again inside the bowel. And then that will create again like a contrast window where you've got darkness inside the bowel and like a darkness in outside the bowel and the bowel wall, soft tissue is dense or appears bright. So you're able to really fo follow it all the way through and delineate it very well. Um So this is a another sign of free um intraperitoneal layer, um that you guys should, should be aware of. So it's called a regular sign. And I've actually seen this uh in clinical practice. Um 11 more sign of a free intra peritoneal air. This is a sign that we see in the pediatric population. Um It's called the football sign and it basically refers to the configuration the abdomen takes um which is similar to an American football um in a pediatric patient where their soft tissues are really lax and they are able to distend. So if you've got a perforation inside the abdomen, um of a of like a neonate, a newborn and that air just builds up inside the abdomen, builds up, builds up, builds up, it stretches their abdominal cavity so that it takes the shape of a football and that how that's how it will appear on the abdominal X ray. Um And this usually indicates that this is a large volume, um pneumoperitoneum, it's not just a small, tiny perforation. Um And these Children are usually very unwell and they're, um, in the NICU essentially. Uh, so now that we've talked about the signs of a real pneumoperitoneum, a real, um, bowel perforation. Um, you know, the regular sign, the football sign, the phosphon ligament sign, um, and the air under the right hemidiaphragm. We've got some mimics of, uh, pneumoperitoneum that you have to be aware of. So you don't make the mistake of calling something, um, a pneumoperitoneum. The first one is chelitis sign, um or what we call a pseudopneumoperitoneum at the I uh below the, I think all like the air, some bowel wall there and these are like folds of A L or bowel, these patients, um large bowel, the uh kind of at the, yeah, a hepatic flexion between the life alone or, or even the um and it makes see and make she saying that that's 339. See you where when fat it's just the bowel. Um because it's positioned there. Yeah, it looks like it's ap but it's perforation in this case, this is just bowel wall. Um So I've, I've seen times um in clinical practice. So you just are aware of if you see free air hems, just another look, there's no bellow. Uh And sometimes you can just refer to previous image patients had because if they into position, um then it will stay the same on the subject. Uh It's not gonna change. So this is just a variant and it has a prevalence of, oh, sorry. Doctor. 0 25%. So it's not common but you might see it as it comes up on exam. It's good to be aware of. Sorry. Doctor Camille. Um, another, I'm not sure if everybody can hear you very well. This is actually a real hi, Doctor Camille. Hi. Sorry. Um, did it cut off? Yeah, I think it cut off. I think when you were talking about the, the sign here, um, I think they couldn't catch what you said there but we can hear you now. Ok. Was the breast of it? Ok. Uh Let me just ask the chart. Uh Should I go ahead and just wait if someone Yeah. And then if, if anyone has any questions from back before. Yeah. Perfect. Perfect. So I'll just repeat this um sign. Um So what, like I said, this is a, basically, it's a mimic of a pneum protium. It's not a real neopin, but it's something that you should be aware of. Um, so that you don't call something free intraabdominal air where in fact it's not. Um So this is a normal anatomical variant. Um, some patients have it and once they have it, it's not gonna change. Um So if you look back on someone's imaging, they will, they will have the same picture. Um So sign of what we call a pseudo peritoneum is essentially interposition of the large bowel between the liver, the spleen and the hemidiaphragms. So, you've got your ascending colon, splenic flexure, transverse colon, um and hepatic flexure. So, hepatic transverse splenic flexure, they're interpositioned between the hemidiaphragms and the rest of the abdominal viscera. Um And once you take the, the abdominal X ray image, um because it's a 22 D picture, um then the bowel wall look like it's um just underneath the hemidiaphragm. And if you don't look closely, um looking for those kind of house straw of the large bowel, then you will call something free of intraabdominal air or in fact, it's not. So if you look close, you can actually see that there's kind of like hatra folds in this region and on the other side as well. So these are just house for folds, it's not a free intraabdominal air. This is just an anatomic normal anatomical variant. Um And it has a, it's not very common, but it comes up on exams and rarely, you may see you may see in clinical practice. So just make sure you're aware of it. Um The next sign is it's a real pneumoperitoneum, but this is a special case. So just like the tension pneumothorax, we also have a tension pneumo peritoneum. And um from what you remember from a tension pneumothorax that happens when you get a one way valve where air is going in one direction into the cavity and it doesn't have an exit pathway. So the same thing, for example, if someone has had a a gunshot wound to the abdomen, for example. Um if they've had um colonoscopy, for example, and they've perforated part of the bowel and air was insufflating into the um bowel and into the abdomen. And that area is gonna build up, build up, build up and start pressuring um the abdominal viscera, the liver, the spleen, the stomach, everything pressure and gets to the center until it compresses the IVC. And basically, that will cause um shock and collapse of the patient. So, in this case, you can see that the, there's like hyperlucency in the Perin cavity and it's a large amount and it's compressing the liver. Um So even the, the liver, the stomach, the spleen centrally and compressing the IVC. Um it, it's rare, I've never seen it in practice. Um But it's just one of those things that may come up on exams. Um This is another uh let's say, extra sign of pneumo uh perineum. But in this case, we've got something called a pneumoretroperitoneum. Um Essentially pneumoretroperitoneum happens when you've got one of the retroperitoneal um viscera or a viscous uh perforates and that air seeps behind the retroperitoneum. So when you take the um uh an image uh an abdominal X ray, you won't see air under the diaphragm, you won't see it free air under the diaphragm, you will see air behind retroperitoneal structures. For example, if you've got perforation for some reason of um the second part of the duodenum which is a retroperitoneal structure. You may get this image. Um If you have per, for example, if someone is having a like retros copy um urethroscopy and they perforated the ureters, then air would go into the retroperitoneal structures and have kind of this picture um of air. You know, you can see the air there, the dark shades um kind of layering within retroperitoneum. So now that we've done with a, we're done with a, so like we said, A is abnormal air. Now, we're gonna talk about b the bowel and when it takes in what is the normal morphology and what is the abnormal morphology that you should be aware of? Um So you guys know we've got a small bowel, large bowel and we have the uh 369 centimeter rule. Uh So there are three. So the small bowel essentially is allowed to have a diameter of three centimeters. The large bowel can, can be up to six centimeters. That's the diameter from one wall to the other and nine centimeters is the allowed um diameter for the cecum. Anything beyond that is abnormal and that you have to call um abdominal uh bowel distension or obstruction. Um So she's gonna talk about the normal small bowel. So normally the small bowel um is a central structure uh centrally within the abdomen. It has the, the, the um sorry, the Judum usually has what we call the valva uh cans which are like circular, um, foldings of the wall running all the way across. They don't just cross halfway, they cross all the way to the other side of the wall. Um, so val clementes, they are very common in the and they get less and less as we go more peripherally peripherally within the small bowel. Um, but furthermore, the small bowel usually has a small amount of air, but you shouldn't see, uh fecal material within the small bowel. As for the large bowel, you guys know that it should be a peripheral structure. So it's localized peripherally within the abdomen. It's not a central structure. So this is abnormal. Um It has um host folds which are folds within the wall that go only halfway, they don't go through the entire um uh wall. Um Also it within the large bowel. It's normal to see a small amount of air and it's normal to see fecal material. So when it comes to the abnormal small bowel pattern, um you can see in this image, you have multiple um loops of bowel. Now, how can we tell whether it's small or large bowel number one, like we said, it's centrally located, which is, which means it's more likely small bowel. And furthermore, you can see the vallea can evens again, which are these kind of folds of the bowel or the mucosa running across the whole length of, of the um bowel wall diameter. Um And if you measure the diameter. In this case, it will be more than three, which makes you think. Ok, this is abnormal. This is distended and I'm concerned that this patient may be having some sort of small bowel obstruction oops. Um, in this next case, we have again, multiple dilated bowel loops. How do we tell whether it's small or large bowel? Um, the things that we pointed out, it's more peripherally located. So it goes all the way to the periphery. And if you follow the foldings within the bowel wall, um, you can see that they don't go all the way. Um, they just go halfway. So these are the host host foldings. And if you measure the diameter, like we said, the maximum allowed for the large bowel is six centimeters. In this case, if you measure it's gonna be more. So this makes you think this patient may be having, um, or is more most likely having some sort of large bowel obstruction. Um There's, there's another sign, um, that you rarely, um recognize on abdominal x rays. Um It's called a thumb printing sign. It's a nonspecific sign. It just indicates um, mucosal edema, which is something you see when you have inflamed, um, bowel wall like inflammatory bowel disease. If you got ischemic colitis, if you got some sort of like diverticulitis, any other uh infectious colitis, um, as well. Um So if you look at this large bowel, if you look at the wall, you can see that there is kind of imprinting thumb, printing what we call from the mucosa into the bowel um, uh lumen, which uh and this happens because the bowel wall, um, is edematous, it's thickened. Um, so you get like these thumbprints inside into the, um, lumen. So it's, it's a nonspecific sign, to be honest, sometimes it's there, but, um, not many people pay attention to it. Um, it's very easy to miss cos that bowel. You may think it's just going like in different directions. Um But sometimes it's good just to keep it in mind in case you do come across it, then you can recommend further imaging like a CT or MRI. Um I think this is a sign that everyone knows. Um It is a very common sign, um what we call a coffee bean sign and you get this kind of like um turning of the bowel um bowel upon itself. Um And this is a sign of a sigmoid vvs and like you guys know of sigmoid, uh VV, sorry is a, a closed loop obstruction where you get twisting of the sigmoid upon its miry and then obstructs from one side and the other and then air just builds up inside the obstructed bowel loop. And because it's kind of twisted from one end that air builds up, builds up, builds up, builds up until it extends into and points towards one of the um, upper, upper outer quadrant, whether it's the right or the left. Um It's difficult to sometimes it takes different directions. So don't go about trying to localize where it's coming from. Um Just learn that this is um a sign of a vulval. OK. Uh Another sign that you should be aware of. Um basically under the category of B is uh pneumatosis, intestinalis, um pneumatosis, like we all know pneumo means air, uh intestinalis means intestine, um pneumatosis. Intestinalis means air within the bowel wall itself. So, intramural air, which is a very bad sign. Um So in this patient, um there are two signs that we can recognize. One is the regular sign that we talked about. So you've got this bowel wall and you're able to delineate it very well because you've got air inside and air on the outside. So they have perforated, they've perforated, there's free air in inside the peritoneum. But if you look here uh within the uh let's say right, upper quadrant, you can see there's gas bubbles, you, you gonna have to like really look closely. You can see there's gas bubbles intramurally within the bowel wall. This is a very bad sign and it indicates that the bowel is ischemic um from whatever cause for example, if they've got um uh like an embolus to the one of the mesenteric vessels. Um and the one of the gut is kind of dying. Um Sometimes we see this in the pediatric um age group and it's a sign of, um, necrotizing enterocolitis. Um So just be aware of this and this will follow on to something else that we'll talk about, um, which is porto venous gas, but I'll come on to it in a bit. Um, s you guys may recognize this from studying about inflammatory bowel disease. You can see that the bowel wall is very dilated, especially in the large bowel, as we, like we said, it's peripheral as it got host folds, it's very dilated, but it's also kind of losing its normal, um, shapes. So it's a bit of lead piping there. Um And this is a sign of a toxic megacolon. Um And if you measure dia the diameter, it's very large and indicates impending perforation. So this is lead piping again that we talked about where the bowel loses its kind of normal morphology. The normal has folds that we expect. And this is a sign of chronic inflammation, um, and inflammatory bowel disease, especially ulcerative colitis. Um, a few signs here. I don't know if anyone's able to piece together what's going on. Um So if I point out you've got a few dilated bowel loops, um And you've got this hyperdense kind of material in the right leg fossa. And if you look closely, you've got some air tracking, tracking along the biliary tree. So if you put it all together these dilated small, these like dilated bowels, they are, they, they are small bowel loops because you've got the val can eventers. Um But also they seem to be apparent appearing from the central and kind of shifting towards the right, um, this hyperdense material in the right leg fossa. Um This is a gallstone actually that has this patient was having um an acute bowel of acute cystitis, but with a severe inflammation, um, the gallbladder is actually fistulated into the duodenum, uh usually fistulate into the second part of the duodenum and then that gallstone tracks or moves along the small bowel. But eventually, if it's big enough, it will get stuck in the um, ileocecal valve and it will obstruct there and cause small bowel obstruction. Um And this is the, the other hand that tells us this is a gallstone ileus is bef because you've got air in the biliary tree. Um And you, you guys know you shouldn't see air in the biliary tree unless, um, basically, you've got some fistula into the bowel or if the patients had a sphincterotomy uh for the ampulla of water. Um, so, going back again to what I was talking about the pneumatosis intestinalis. So we said pneumatosis intestinalis, um is air inside intramurally within the bowel because the bowel is ischemic or essentially it's dying. Um And because you guys know that the portal vein drains the bowel, the air is gonna also go, go with the portal vein and drain into the liver and the air in inside the liver is gonna basically follow the um, kind of venules and sinusoids in the liver and take the shape of portovenous gas. Um You might ask, why is it portovenous gas? Why is it not like the pneumobilia that we just talked about here? Few ways to differentiate. Um, portovenous gas usually, um, it peripherally extends peripherally inside the liver. Pneumobilia is usually central, also a clinical context. So if you've got someone who's got gallstone ileus, um then it's more likely to be pneumobilia. But if you've got someone who's got ischemic dying gut, uh then it, it's porto venous gas, it's not uh a pneumobilia. Ok. So now we're done with A B um that was a lot. Uh We'll move on to D which is densities and calcifications. Hopefully, this should be a short part. Um So densities, densities and calcifications that you should recognize abdominal X ray. You've already pointed out the normal anatomy, um the ribs, the vertebral column, the pelvic bones, the hip bones, the uh femur, um you should know the normal anatomy, but sometimes you may see other densities um on the abdominal x-ray, for example, um in this patient, you've got um within the region of the right kidney and also right upper quadrant. Uh There are a couple of things that you can see, you can see some linear hyperdensities. Um And these are usual whenever you see this, this, these are surgical clips. Um uh What, what do you guys think this is most likely representing what kind of surgery has this patient had? Usually this is a um cholecystectomy um clips. Um But other those other than these clips, you can see um paravertebrally within where you expect the kidneys to be. You can see some kind of irregular hyperdense material which take the shape of the caliceal system of the kidneys. Um I'm sure you may have heard about these, but these are calculi um within the kidneys. But when they take this kind of irregular large shape, then we call them staghorn stones. Ok. Um This is something a bit subtle. Um So we know a normal anatomy, the ribs, the vertebral column, the pelvis. Um So going through the ABDO X um systematic approach, have you got any a as any pneumoperitoneum? No, no, I can't see any pneumoperitoneum. Um Do you have any dilated bowels? No, we can see just some fecal material in the ascending colon. Um And then do we have any abnormal densities? So, if you look closely um at the level of L4, just to the right of it, um there's a small hyperdensity and this, this is following the course of the path of the right ureter. Um And this was, this is actually a small um ureter calo within the middle third of the or actually the proximal third of the ureter. Um There um another abdominal X ray again, um going through the ABDO X approach, can't see any pneumoperitoneum um, you've got just some normal amount of gas, um, and fecal material within the, uh, large bowel. Um, but looking closely, um, at calcifications and densities, looking at the pelvis, you can see there's a small hyperdensity in the pelvis. Um, and if you also look closely, you can see just the outline of the bladder there. Um, this, uh, tiny cal cal hyperdensity is a, a stone which is actually lodged into the right, it was icu uric junction. Um There's stuff you might see, we don't do abdo x rays to look at stones. Um as a diagnostic approach, we only do abdominal x rays to follow up stones. So sometimes some patients may have a stone in the right V UJ but may not be obstructive and you just send them home with um conservative treatment as in drink lots of water, uh maybe take tamsulosin and they may be able to pass the stone. And if you get them another X ray, um you may be able to see that that stone has actually passed. Um I I'll get the text up for this one. Quite interesting. Uh So this patient, if you look within the pelvis, you can see there's kinda like tiny rounded hyperdense material. And also by now, we know that this is following the course of the ureter as it goes from the left kidney all the way down into the pelvis and into the bladder. Um This pattern of kind of stone formation or um stone stone fragmentation. Actually, we call it Stein Strasse, which is a German word meaning Stone Street. So this patient has had extracorporeal shockwave lithotripsy for a big stone in the kidney. And once sometimes uh when you have shockwave therapy for those kidney stones, the fragments will go down the ureters and may lodge within the, within the ureter and obstruct. Um They cause this kinda s cobblestone appearance within the ureter which we call a steins rossa. Um So the most common side for these uh steins Strus to form is in within the distal third of the ureter. Second, most common is within the proximal third and the last most common is within the middle third. Surprisingly, uh we've just got a question in the chat. So um somebody's asking why is the bladder more dense if a stone is in the Vesico ureteric junction? Is the, is it the previous image? Uh I believe so, yeah, this image, it's, it's not really more dense. Um This is just uh this is a, let's say a better windowed um image where the soft tissues are better windowed than an abdominal X ray. So you can see even the liver shadows are well illustrated. Um and the bladder is essentially soft tissue. So you can see it better. It's just the windowing of the image. Um A a stone at the V is not gonna affect the density of the, of the urinary bladder itself. The only thing that is gonna affect the density of the bladder itself is if you've got uh stones inside it or if you've got contrast material inside. Um So that is time stress that we were talking about. We're just gonna um past that. Um, other calcifications and densities, um which are really important to recognize are vascular calcifications. Um Sometimes there may be like tiny calcifications within, you know, um the internal iliac or the external iliac vessels. But an important calcification to recognize is one within the, within the abdominal aorta. And if you look closely, you can see a kind of actual calcification. Um but then what looks like an abdominal aortic aneurysm. Um So this is something you should also be able to recognize on after x-rays. Um Other calcifications we may see are calcifications in the midabdomen. And if you try and kinda make up where this is, you can tell that it's kinda coursing from where the spleen is and going across the abdomen. Um kind of towards the region where you expect the duodenum to be. So these are classifications within the um pancreas in a patient with chronic pancreatitis. Ok. Um But tiny punctate calcifications may not be visible on the ABDO X ray, you will need a CT to actually see them. Um This is kind of um referring to the bones in this case. So, in patients who've got inflammatory bowel disease, um uh so not just inflammatory bowel disease in patients who've got ankylosing spondylitis. Um you know, the bones um are affected, especially the spine and the sacroiliac bones. And in these patients, you get inflammation within these um psych iiac joints until they start to kind of fuse together. Um just like you see in this patient, normally, there should be a bit of a gap between the joints, but in this patient, they've almost fused together. Um Another sign of ankylosing spondylitis. You will read about in the, in your books um are the dagger sign and the bamboo sign. So the dagger sign is named basically because it looks like a da dagger and it refers to the calcifications of the interspinous ligaments. Um You guys know that we have the spinus processes and there's a few ligaments um between them. So we've got the supraspinous and interspinous ligaments. And when they these calcify, you've get, you get um a dagger sign. Another sign in ankylosing spondylitis is what we call a bamboo spine. Um because it looks like the bamboo um shoot. Um uh you get kind of synd isophysis. So you've got no normal vertebral bodies. But because of all the inflammation, you get um osteophytosis and syndesmophytes forming on the edges of the vertebrae and they will reconnect together across the intervertebral discs and calcify. So it looks like the spine is just all continuous and looks like a bamboo shoot. So this is why we call it um uh bamboo spine and ankylosing spondylosis. Um So now we're done with densities and calcifications. We're just gonna quickly talk about um organs and soft tissues. Um So we talked about the um organs or soft tissues that you can see in abdominal x ray, uh mainly the liver spleen. Um the urinary bladder, you can see the kidney shadows as well. Um Sometimes it may be, you may be able to recognize um hepatomegaly or splenomegaly. If you look at the liver contour, you can see that it's quite enlarged and extending all the way to the right leg across and this is um kind of hepatomegaly. Um Sometimes patients may have this kind of tail to the liver, um which is which which is a normal anatomical variant and we call it a WELS lobe. Um So if you look at this patient's previous imaging, if you know this liver has not changed, then this will represent a an an anatomical variant, which is just a wide dose lobe. If they did not have the liver would was much smaller on previous imaging. And then now it's this big, then this is Hepatomegaly. Um the spleen as well, he may be able to recognize it as it goes across. Um the left upper quadrant and extends into the midabdomen. Um if the patient gets splenomegaly. Um So just like in this case, you can see the spleen shadow is quite enlarged and extending all the way from the left upper quadrant towards the kind of midabdomen. Um So few things that we may forget to check in abdominal x rays. Um Frequently we forget to check it are the um inguinal um let's say rings or the um hernial orifices. So always check the hernial orifices on an abdominal x ray. You may be able to see some bowel loops passing beneath the um inferior pubic crem. Um just like in this case, you can see a small bowel loop passing underneath the inferior pubic Remus and this is an inguinal hernia. Um We've just got another question um asking um in this one, is there any air above the liver? And this one or the previous one, this one? Uh I think it was this one. Yeah, this one not, not really, you can see some air. Um the Hepatomegaly one. The this one. Yes, I think so. Yes. So this is not air uh within the liver. This is actually or not air. I think they, they might be referred to the side here. This is just a fat plain. Um You guys think it was the previous one? Sorry, this one um just waiting for them to confirm, I think I, yeah, this one. Yeah. Yeah, I think they're referring to the fat planes um just in this area, I believe. Um So you guys know that the fat is dark. So whenever you've got like um an interface between soft tissue, which is um hyperdense and fat, which is uh more lucent. Um You may think that there is air, but this is actually just a fat plane. Um If you guys are referring to what's above, then this, this is just the lungs, this is lung, tissue, lung tissue in this region. Um There's no free air in these cases. Same here. We've got some fat plains um kind of fat plane here as well. Difficult to see, but it's there. You can see kind of the transition between the outside and the inside. The same here as well. You've got some fat plains and fat planes here. Um But there's no free air. So this is the hernia one. So finally, we're gonna quickly just talk about external objects, lines and tubes. Um So in this image, I've got a few examples of um kind of foreign bodies or objects that you may see in abdominal x rays. The first one that we talked about like these linear hyperdensities, they're usually surgical clips. And if they're in the upper quadrant, most likely they will refer to uh cholecystectomy clips. Um In this case, you've got this kind of cage like appearance um in the mid abdomen, let's say um just to the right of the midline and it's kind of following the course of the inferior vena cava. So this is an inferior Vena cava filter um which we put in the inferior cava in patients who cannot receive um anticoagulation uh but they, they've got, uh for example, they're uh either at high risk of getting a DVT or they've got a, a DVT, but they cannot have a um anticoagulation to prevent it going to the lungs. Ok. Um There's this material as well in the right leg fossa, kind of like circular material. Um It's just one of those things that you have to memorize what it looks like, but this is a capsule endoscopy. Um And within the vertebrae, you can see these kind of hyperdense square like um shapes and these are vertebroplasties, which is um synthetic material they put inside the vertebrae um to prevent them from collapse. And on the outside, you've just got some like external wires connected to patient like an ECG wire there, monitor wire. Um Something else you might see incidentally on some X rays or even CT scans. Um This is a uh gastric banding. So you guys know that the gastric band um is of two components. You've got the band itself and then you've got the tubing is connected to a port. Um This port, you can control it to inflate the balloon which is um overlying the gastric fundus or you can deflate it. Um This will deflate the balloon which is overlying the gastric fundus. Um One other, let's say, um external line you might see frequently to be honest. Um Is this um tubing within the peritoneal cavity? And you can see it's coming from kind of the right elect fossa, going inside the abdomen, from the left Ilic fossa there and, and terminating within the kind of mid abdomen. Again. Uh This is actually a peritoneal peritoneal dialysis catheter. I think that might be the last one. Yeah. So uh we've just talked about a quick approach to abdominal x-rays. Um The pneumonic is ABDO X. Um just follow this systematic approach. It'll make your life way easier. Just remember, always rule out the most important thing which is free intraperitoneal air. So that's a and then look at the bowel configuration. Is there any signs of obstruction? Um Is there any other signs like thumbprinting? Lead piping? Is there like a sign of toxic megacolon? Um And then move on to d look for densities and classifications. Like, can you see any stones? Um Can you see the contours of the vessels like uh the calcified donor aortic aneurysm? Um And then look at your organs and soft tissues, look at your liver, um, outline, look at the spleen, outline the kidneys themselves, the bladder. And then finally, once you've done all that, um, make sure you check the bones and d so that's season cal cal medication like rule out any fractures and finally look at your external objects, lines and tubes. They got like an energy in um any external drains, catheters any surgical clips. They give you lots of indications about um the previous background of the history of the patient. Um I think that's all of it. Um Happy to take any questions. Um We've got one student asking to you to explain um intramural gas and they just want to understand how to identify it or differentiate it from the normal intestinal lining. Yeah. So I'll go back to and just let me know if you can see the the slide. I think it might be here, this one. So intra can you see my slide? Yeah. Yeah, we can see that. Yeah. Um, so intramural gas. Um, so, you know, normally, um, the bowel should, we can assume this is normal. The bowel should, should be, um, thin, crisp. Uh It shouldn't, you shouldn't really be able to visualize it so well. Um, as in, you can see what's outside and what it's what's inside. Uh, but it should be thin and crisp. It shouldn't be thickened. Um, and it shouldn't have like any air within the bowel wall itself. In this case, if you look very closely, you can see there's like gas bubbles within a thickened bowel wall f there. So these are gas bubbles inside the, um, the, um, the bowel wall. So intramural gas and it basically indicates that the bowel wall is, the bowel itself is ischemic and that it's basically dying. So you as a byproduct of, um, the bowel wall necrosis, you get production of gas, which, um, by venous drainage goes into the bowel wall and then drains via the portal vein into the liver. Um So this is pneumatosis, intestinalis or the bowel wall intramural gas that we were talking about. So, again, inflamed. So this kind of represents where the gas is when the bowel wall. Any other questions? I don't know if that explained it. Um I mean, fair enough, it's very difficult to see um because you've got all these shadows, um it's more, more clear on um CT scan. So after this, if you can just go type into Google um Radio Pia neato intestinalis and then all the images will come up and you, you're able to differentiate it. Any other questions? There's no more questions at the moment. I'll just give everyone two minutes in case there's anything else. I hope that was helpful. Um I appreciate, you know, the not the most detailed, but it's just a quick tutorial about how to approach after X rays. Um But yeah, just follow this structure that should make your life easier. Yeah, I think that's all the questions, but thank you so much for delivering this teaching. It was really, really comprehensive. Um And thank you everyone for joining as well. Um There'll be a feedback form sent out after this has ended. So um please make sure to fill that out and you'll receive your certificates as well. But yeah, thank you, Doctor Camil. Once again. Thank you. Thank you for organizing it. Take care. Bye-bye. Bye-bye.