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Right? Um Well, that's it. We're ready to begin. We are fine. Ok. Is everyone settled and ready to start? Fine, great. Um For people online, can I just confirm that you can hear me and that you can see me and that you can see the slides if that's ok, please. Stunning. Thank you, Aisha. Um And can I just check that you can see the laser on the screen? Yes, everyone says yes, we'll round. Okay. Perfect, good. So let's start. So my name is Catherine guys. I'm a final year medical student on the exposure committee. I'm the clinical rep that this is Helen Presidente. Um So today we'll be delivering a teaching session on abdomen X rays. Please forgive me. I'm going to be splitting my eyes between here, here and the chat with people online. Um So yeah, we'll get started. I think that's yeah, we can begin fine. So what we're going to cover today is um we're going to start by reviewing abdominal anatomy at the start and then going through the breakdown of abdomen x rays um with different radiological signs that we want to pay attention to. Um We have interactive case presentations kind of mingle throughout the thing throughout. Um And then find me a kuchar's because he doesn't like acute um so fine. So just to recap um this is an abdominal X ray session. So we're going to start with the anatomy. So this is just to demonstrate the nine regions of the absent abdomen. So just I'm hoping that you guys have probably seen this um kind of image before, but on the right side, we have the right hypochondriac region which is pertaining to being around the rib cage. So that's the cartilage of the ribs. The epigastric region describes um epi which is above or upon and gastro meaning the stomach, we have the right and left number region because it's either side of the lumbar spine. Then you have the umbilical region pertaining to your umbilicus, your belly button and then finally, the right and left iliac region, which is to do with your iliac phones and your hyper gastric region, which is hypo below the stomach gas room. And then if you take a look at the image on the right, I put the side by side because it's quite easy to think of the nine regions on their own. But when you think closely about what organs like in which region, then it helps you to identify and look um abdominal x rays with a bit more of a logical structure. So that if something is looking abnormal, you can look at it and say, oh, actually, I knew that this organ is in this region. And if this is inflamed, this would give this kind of appearance. So moving on, this is just to recap the okay, you can't do that okay. This is just to recap um the position in which abdomen, x rays are taken. So for the majority of abdominal x rays, they're taken in the supine position. So that's where their patient with the patient rather lying on their back. As you can see here with the X ray beams entering anteriorly diverging, exiting posteriorly and then being on the imaging plate and the image produced is that of what you see on the left, my left, your right. Um So it's as if we're looking at a patient lying down on the table and then labeling it, labeling it as um that. So the left hand side, it's lazy. The the left hand side is on this side as you know, and the right hand side is on this side. So just keep that in mind when you're bearing um bearing in mind anatomy, some texts, do you say like a left lateral decubitus position is used, which is where the patient literally lies on the left side. And they take, they get like anteriorly um and posteriorly um the X ray beams exit, but that's not really used in today's practice. So I'll just let you know about that, but I kind of forget about it. So this is our first interactive bit and just something I wanna like really reiterate in the session like this is an interactive session and please don't worry about getting things wrong. Like I know people get really embarrassed and shy but we are here to learn, learn. So please like involve in for your hand up and if you get it wrong, it's okay. I'm not judging you, so don't judge yourself. So it's fine. So this is an abdomen X ray. Um And I just kind of want to gauge like how much you guys know. Um we're seeing you messages, how much you guys um uh how much you guys know about abdomen x rays. So I'd like you to identify, pick a letter and identify um any structure. So I'll split it like half between you guys here in person and then half between the people online so that they can get involved too. So does anyone want to be very pick a letter and take a structure like and people in mind you guys can, it's kidneys. Excellent. What's your name, Amy? Excellent, Amy. Good job. So it is the kidneys and as you can see, um it is a bilateral structure which Amy correctly identified. It's not always possible to see the kidneys. But if I can humor you, there is a slight bit of density here at the bottom, which is the lower pole which extends all the way around on this right hand side and then on the left hand side, it's slightly more clear with the laser. That's just what I'm trying to outline there. So that's the kidneys. Um And as I said, can't always be seen, but there you are. Um So well done. A me next up anyone else to name structure say that is be the liver be is, in fact the liver. What's her name? Lulu? Perfect, well done. So be is the liver and most times you can actually see the liver because it's quite a dense structure. Um and it exits just underneath the rib cage on the right hand side. So yeah, very well done. Really people online. Um Do you want to have a stab and pick a letter name, an organ if you would like to be shy? Like you a question? Oh Silence online. It's okay if you get it wrong with Ritalin. Um anyone in person want to have another step? O E says Pelvis, he says Pelvis excellent Aisha well done. So e is pointing yes to the pelvis, but specifically the iliac bone of the pelvis. So yeah, very well done. And as you can see, that's what forms like half of the abdominal picture. So when you're looking at an abdomen X ray, you want to be sure that you've got the base of the pelvis, which is the structure hate. I'm not gonna give that away right the way to the top of the diaphragm, um, which is where the kidneys sit. Um, so, yeah, well done. Aisha. Perfect. Anyone else online or in person just throw out these answers and letters. Um, yeah. Anyone things that we saw, should I just go? I'm here, Christmas. It's ok. Is what? Say that again. D the Iliac crest. Yes. Amy. Well done. That is not wrong. That is, in fact, right. So d is the Iliac crest say that Emily Emily? Okay. Anyway, is um d sorry, is the Iliac Crest. Um So yeah, well done. Um Next up anyone online or in person, anyone can have it because I want to move on going. Really can F B the screen? I can see why you would think that. So F is roughly in the position that the spleen would be in. Not gonna, I don't actually think you can see the screen on this X ray but close, not quite have another guess if I can, if I tell you that F is some air, whereabouts do we think that is going to be sitting stomach? Yes. Um But not this time. Where else, if not in the stomach, where else would the air b stunning. That is it, what's your name? Sorry. Real X and Gabrielle. So that is air in the descending colon. It is quite hard to see. Um But on most X rays, you will see like an air pattern and we'll go through that as we go through the session. Um I'm just gonna go through the rest of them just in the interest of time. So we've done a is the kidneys as rightly identified be as the liver. Let me just go. Uh Oh, lovely. Look. V is the liver. Um C was the psoas muscle. So, if you can appreciate here with the lasers, that bilateral structure coming down is what helps to stabilize your spine. So that's the, so it's contour coming through. Again, it's not always visually because of the bowel, because of the bowel gas. And the iliac crest has was identified by Amy. Um E was the iliac bone which again, you can see on either side, this is pointing to the sacrum which is the base of the lumbar spine and the cocks it here at the bottom. Then you have some bowel gas, which is here on the left hand side and then find you the pubic synthesis. So this is just to show you what normal anatomy looks like. We will see more normal x rays as we go through because normal anatomy and abdomen, x rays does actually very, quite often. So the more normal ones you see the easier it becomes to identify what's abnormal. And generally you want your area of interest to be from the diaphragm. So you kind of can't really see it here, which is G tube anyway, from the diaphragm all the way down to the pubic synthesis and naturally the flanks or as much soft tissue as you can get on. Um in like skinny patient sympathy, patient's and kids. It's quite easy to get it all on one film. For, for patients who are like slightly larger, there were bigger body habitus they tend to do to landscape films and get half and half. So leaving on this is just to reiterate what we saw if you were like struggling to see the previous image. But again, you can go through this in your, in your own time just to like study the soft tissue structures and then this image. So with the nine regions of the abdomen, remember I was saying like, it really helps to look at it um in terms of what organs I were and with that, if you match up to this picture, it helps you um consider like common things are common. So where you like me to find um where you're likely to find different pathology. Um So yeah, that's pretty much it. I don't want to dwell on that too much but have a look at that and yeah, to side. Um So yeah, just before we move on, does anybody have any questions? And I put here in brackets that there's no such thing as a silly question because like I said, the spaces for learning and I want you guys to leave today's session being like, okay, I don't understand something I asked about it and now it's good and chances are there's somebody else who's thinking the same. So yeah, any questions before and you've uh any questions from people online, you know what slide, by the way on the recording will be available in med or if you have signed up on New York. So you'll automatically receive like a link after you something about uh and down in his life. Lovely. Thank you, Helen. Okay. So moving on. So as with any type of imaging investigation, you are using radiation. So at the end of the day, you have to um you have to figure out if the benefit of the benefit of like why you're taking the X ray out, raise the risk associated with it. So this is just a list that I got from the Royal College of Radiologists, which is essentially um I think it's like eight or nine reasons why you end up taking an abdomen X ray in clinical practice, abdomen X ray actually aren't used that often. It tends to just go straight to see T or ultrasound depending on the pathology. Um They're just going through the list quickly. We have obstruction, we have exacerbation of inflammatory bowel disease, palpable mass. So that's basically tumor's or any other obstruction, constipation, acute and chronic pancreatitis, sharp or poisonous foreign body, smooth and small foreign body, um and blunt and stab abdominal injuries. So, basically trauma. Um So with any imaging investigation you want to take, you have to ask yourself is this really necessary? And if so does it fall into any one of these eight or nine, which I'm not gonna lie 10 times out of 10, it probably will be high. Yeah, exactly. So, um yeah, exactly. That, so with X rays as we saw in the previous images, there's a lot of bowel gas, there's a lot of soft tissue structures. If you're looking for one specific small thing, X ray is probably not the most specific and sensitive for finding that whereas CT is much more detailed and so MRI much more detailed to see those structures. Um but it is good as an initial screening tool if you're looking like again, CT is a massive massive dose of radiation. So before you subject your patient to that, sometimes it helps to just have an initial X ray to rule out whatever else you might be thinking if it's any of these. Does that make sense? Perfect. So um if you guys were here in last week's session before interpreting this is with a focus on our skis. Before interpreting any investigation, you always want to introduce yourself, wash hands done. PPE check that you've got the right patient details. I say this because like one of my mocks stations we were given um I think it was an abdominal X ray and I didn't check that it was a patient's name. So I actually was reading the X ray but for the wrong patient and my management was all dependent on the wrong patient. So please please please double check your demographics that's name, date of birth and it can be either I D number or address. Um And then you want to note the date and time of the film and again, as I was saying, with the benefit risk, the specific reason for the film. Um and the last one is underlined because this is so important you really want to compare and see if they've had a previous one. If they haven't, then it doesn't matter. This is, this now becomes your baseline. But if they've had a previous X ray and there's something that's looking a bit odd and you're like, oh was this here before by comparing it with that previous that will depend on whether you are addressing that specific abnormality in this acute episode or not. Um So yeah, that's something to be aware of. Now going through abdominal x rays. I like having a system to everything because when we're doing Oscars, I'm just in general practice. It's nice to have um something that you can fall back on if you're a bit confused what you're looking at by having the structure. Um It just helps you to go through it systematically. Um Now this is the structure I'll be using for the remainder of this session, but there's absolutely no pressure for you to use this like after today's session, if you want to come up with something else that's absolutely fine. But this just works for me. And yeah, I just want to show that show and share that with you today. So um the acronym is ABDO X because it's Abdo X areas. Um So we're gonna start with a for air where it should and shouldn't be. Um We're going to get some details beef about position, size and wall thickness because that's important. Um D for calcification and bones d actually stands for density, sorry. Um Oh for organs and soft tissues and find the X. This was cheating but external objects and artefacts. So starting with a abduct X. So uh as we established in the beginning only belongs in the stomach and the belt if it is not in the stomach, if it's not in the bell than anywhere else is abnormal. Um And as we were saying, last week, with the different densities, um it actually helps to show in contrast to the soft tissue structures like surrounding um that helps you identify what type of pathology you're dealing with. Um And again, it just forms more of a natural contrast. So as I was saying, and as you can quite nicely need to stop playing with this laser, sorry. As you can quite nicely see um the synthesis pubis is at the bottom of each image and then you go to the top and you can see the right and left costophrenic angles you have laterally, both both what we call the flanks. So this is just soft tissue margin here and here and then you have the bowel gas and the other structures which will go through in more detail. And yeah, so our first radiological sign is called, sorry before I get into this, I just want to show you that these are both normal. I know it might look a bit confusing for now, but this is just what normal bowel looks like. The large bowel tends to like fall around the like perimeter of the abdomen where the small bowel tends to be more in the middle. But it's not always like that as we know, structures in the human body are very fluid. So they don't just stay there forever. Things kind of move around. But this is just to show you kind of what normal looks like. And as we go through it, hopefully you can, I guess kind of remember this and compare it against it. Um So yeah, I'm just gonna refresh my, I'm not saying okay. So the first time we have is um Rigler sign. Now last week we were talking about chest x rays and pneumoperitoneum. Can anyone tell me it's kind of their what? I ruined it. But can anyone tell me what pneumoperitoneum means? Everyone's feeling brave and online people. I'm watching the chat too. So please jump in if you feel like a I watched any takers for what pneumoperitoneum means. Yeah, to apply the same structure, say that perfect, really very well done. So literally in the peritoneum, that's the beauty of medicine. Like some of these things are actually just very logical and if you start just break it down. So pneumonia means air in Greek Peritoneum. I don't know if it's Greek Latin, whatever language, but it just means, I think that's just English, isn't it? Anyway? Paratonia is the peritoneum. So yeah, so that's uh in the peritoneum. So Erin Peritoneum, um as we will see is actually just not normal. So regular sign, um named after, I think it was Thomas Rigler who is a radiologist way back in way back whenever, um, it's what they call the double wall sign. So this is a sign of pneumoperitoneum seen on an abdominal radiograph when gas is outlining both sides of the valve wall. So as I said, gas only belongs inside the about if it is anywhere else other than these structures. And I think it's the stomach as well, then it is abnormal. So what makes regular signs special is if I can get you to appreciate with where these arrows are, you can see a slight thickening and what appears to be slightly thicker because there's outlining the soft tissue structure on either side. So that it gives it a slightly more thicker appearance. And yeah, essentially that's regular sign. It's nothing too special, but it's just something to be aware of and on the right your my left, your right on the other image, we can see regular sign coming in here nicely and kind of similar to last week's chest x rays we saw, you can also see underneath the diaphragm, which is actually more of a sensitive marker for pneumoperitoneum compared to um getting an like plain abdominal film. So that's that. And something that I wanted to highlight is um Rigler sign is only actually seen with pneumoperitoneum of like massive massive amounts of air. So the fact is you're coming up with, I think it's one liter, 1000 mL. So 1 m of air you need in your abdomen in order to be able to see Rigler sign. So like that's, that's what this is 500. So two bottles of this filled with air in your stomach. That's how much air you need. So, um it's not a very common sign but something to watch out for. Um And it occurs due to perforation, trauma or yatra genic courses. So um like lack Kohli's which is removal of the gallbladder through keyhole surgery, they pump the stomach with their massively and if that perforates and you end up with all of this air inside the peritoneum, which is not great. Um So the next time we have up is the football sign. So this occurs due to an even more massive peritoneum, pneumoperitoneum rather which outlines the abdominal cavity. So this is usually only seen in Children not exclusively, but it's quite rare to see in adults. Um, and different causes of it is more rotation of the Medica Hirschprung disease, which is, um, what they call an aganglionic colon. So it's a section of the colon that is not properly innovated. You have a meconium ileus, which is where you get meconium, which is a thick, like green substance obstructing the bowel and intestinal atresia, which is where the intestine just doesn't form properly. And these can lead to different versions of bowel obstruction, which it perforates creates this what you can see like rounded football sign. So I hope you can appreciate here in the top image that the abdomen is actually very distended in this little kid. Um And it kind of outlines the different structures of the parity and here in the bottom when it's slightly less clear, but you can see that it is creating that football circular shape. Um Different different literature struck different pieces of writing, argue about like what kind of football they're comparing it to actually just doesn't matter. It's a football, it's surrounded structure and that's what it looks like in the abdomen. Um And then lastly, you have pets occult disease and again, Yatra delic. So um they're doing a procedure and they're pumping up loads of loads of air in the peritoneum and it explodes, that's what creates um the football sign. So moving on to the bowel. Okay. So now if you can see the acronym and the top. I kept, I kept keeping that here so that you can keep seeing it and hopefully get familiar with the structure of how we're gonna interpret X rays. So, moving on to the bow. Has anyone here heard of the 369? Rule? Nope, someone's, there's one not, I'll take, I'll take the one not fine. So the 369 role is essentially delineating the types of measurements you hope to see and what we call normal. So that's three centimeters for the small bowel. So here you can see the what they call the valvular a condo venter's um crossing the entirety of the lumen. And that just shows you it's small bell. Um And these are just yeah, mucosal folds across the abdomen. It's very simple. But the way I remember is Combivent is cross see and see does it um And then six centimeters for the large bell. So up to six centimeters is normal, any larger than that we're looking at like, oh, is this, is this suspended? And how astra is small pouches which is called by circulation. So kind of like swinging, squeezing of the patches which give the colon it segmented appearance. Um And that delineates um large bell. I think that's all I have to say on that. Um But yes, so as I was saying before bowel gas should only be seen, I'm going to keep saying it because sometimes I forget. But about that should only be seen in the stomach or in the bell, anywhere else is abnormal. Now, um as we're looking at, then if you remember the image at the beginning, the nine regions of the abdomen, the large bowel tends to lie on the periphery where is the small bowel tends to lie more centrally. But of course, that's not always the case because as I said, things are fluid, but this diagram kind of nicely demonstrates that the large bowel is here crawling on the outside. And that um so ascending colon, transverse colon, descending colon um sigmoid colon coming down to the cecum and on this side, we have less of the large bowel visualized. You see the small bowel coming through um centrally. Um So yeah, pretty much question break and I guess some time for snacks if you want to get some snacks. Does anyone have any questions before we move on again? There's no such thing as a silly one, please ask. Hey, Lily, what's up? Yeah, let's go. 90 sugar. No nine is coming up site later. Sorry. Spoiler nine is coming up later, but we'll come to that. Yeah. What is the three centimeters actually measuring between, that's it. So that's an excellent question. Um So what the three centimeters is measuring is the lumen about of the small bell? So you're measuring, sneezes quite big, but you're measuring from one side of the bell across to the other. Does that make sense? You're not measuring between the folds because who cares, but you're measuring top to bottom. Um And yeah, and, but the large about it's exactly the same and that's just to give you a sign of like, again, it's not fixed like if it's 3.1 centimeters, no one's going to cry, but it's just to have like a rough like guideline figure of what we perceive as normal in an abdomen. X ray. Does that make sense? Cool. Um Anyone online have any questions pre and the ferritin will come to. Yes, Olivia, sorry, I missed this. Um Yeah, you're right. That's what you refer to you. Is any other questions, Sediq. So yes it is. So this is um I want to say it is because it does measure three centimeters and the text underneath this image was actually just showing that it was normal. Um It's it's if it's distended, it does look this clear but it tends to be a lot larger, so much, much larger than three centimeters. You're looking about four or five. But I do believe this is actually a normal bowel. Most abdominal X rays don't look this pretty. Um Yeah, that's just for demonstration purposes. Is that all right? Cool. Um And then getting across any more questions before we go on, I think we should stop for some pizza. Should we do that? I think we should. Okay. So people nine just go grab yourself like a quick coffee or biscuit or whatever. Um, you know, I talked to the people in line. Sorry, but yeah, we're going to resume and literally about five minutes. Um, yeah, and we'll continue. Um, and any questions you have in the meantime, please just pop them in the chat and I'll address that when we come back. Thank you. It's to screen. That's okay. People online we're about to begin again. Um uh, are you back slash we're gonna stop. Um, I hope you managed to get some food. Um Yeah, sorry. It's been limited by the screen. It's fine. I'll just use the touch program sweat. Oh, no, because you're on them. Yeah, it's supposed to on that screen. So it shows up in marriage. Uh Oh, great. Okay, fine. Thank you so much. Um, okay, let's continue. Fine. So, abdominal pain, um, with bowel obstruction, um, the main clinical presentations that you tend to be looking at is abdominal pain. So colicky or cramping is what you tend to see in your exam stem. And in clinical presentation, patient's will say like, oh, it's really terrible pain. It's the kind of pain that causes them to double over. They tend to be vomiting a lot. Um, and this because early in proximity obstruction, but late and distal obstruction, I'm not going to lie to you. In clinical practice. It tends to be small, bowel obstruction is lots and lots of like green, almost like bilious kind of vomiting. Whereas large bowel obstruction tends to be slightly less vomiting. I don't know the color of it, but just slightly less vomiting. Um, you don't have abdominal distension. So even in larger patient's, you will see that their body habitus is a bit rounded. And when you're like palpating the abdomen, um, you'll feel either lots of fluid or lots of air and we'll just feel just very uncomfortable. So exercise caution with that. Um, and then absolute constipation. So it if there is obstruction, then the patient will report like not having pude um not having been able to open their bars even with drinking water that just causes them to be sick. So, as you can imagine, this is just like all very uncomfortable, but I'm telling you this because this is relevant to the next couple of x rays we will have a look at. So this is small bowel obstruction. So do you remember what I was saying about the whole valvula convent is crossing the lumen of the lumen of the bowel here? You can see and I hope you can appreciate that it's slightly wider than three centimeters. And you can see the valvular convent is crossing all the way across. Um It tends to take up in this image anyway, it's taking up more of a central position, but again, it can lie wherever. Um And yeah, pretty much is it just to show you what it looks like on the right side. I feel like it's better visualized, but you can see the crossing of the valvular convent is again and it's just line all the way through. So it's particularly distended on this side. Um And down here in this region and small bowel obstruction causes tend to be classically adhesions. So it's seen in your patient who had a surgery, let's say a hysterectomy 20 years ago. Now they've come in with all this pain. The reason why adhesions calls bowel obstruction is because the bowel tends to get trapped in the adhesions which then causes like stricturing. And if you imagine kind of like a sausage balloon, if you're holding it in one particular place, you're getting a build up of pressure on either side of it, which tends to cause the bowel to be constructed. Then you have I'll E S which is, is like paralytic were basically where, um, the parastatal tick motion of the bowel is lost. Um, and if you imagine again, it's a build up of feces in one particular area. It's not pushing through causes obstruction, build up of pressure, then you have less common causes. So hernias, um, can anyone tell me what a hernia is just a simple definition? Perfect. Exactly that. So there's nothing more to say, as you said, part of the valve poking out into the abdomen. Um, and that causes obstruction. Can't remember by what mechanism. But if you imagine it's, it's a blockage, it's been pushed through a small space and find me, tumor's are very, very unlikely to cause a small bowel obstruction, but they still do in rare cases. Um So that's just to show you what small bowel obstruction looks like. And then we have large bowel obstruction. So we were talking about the 369, also up to six centimeters is what we would classically call normal in large battle. And on the, the I keep getting confused, my left and right. But on, on the first image, we can see that the large bowel has lost the Hellestrae Shin, which is that succulent like patches that we saw, which created the kind of like finger like appearance on the side. Um And over on this side. So coming down in the descending colon and descending code on it's slightly more distended and I hope you can appreciate maybe down here, it's a bit more distended. It's a lot clearer. On the second image here, you can see this is definitely measuring more than six centimeters and it's really, again, really large, really distended. So again, classically, your patient will present with abdominal pain quality in nature. A kind of crampy, not able to open their battles. Pardon me? Sorry. So large bowel obstruction causes malignancy tends to be the main cause of large bowel obstruction along with diverticular strictures. So that's the diverticular disease where you get out pouchings of the bell. Um And finally you get hernias and volvulus, volvulus is basically twisting of the bell in on itself. Um, and then we were talking about, you know, the nine rules. Sorry, I don't actually have a slide on this, but the nine rule refers to the cecum. So the cecum is, um, let me just go back so I can show you this clearly. Oh, see him. Sorry. Let me just find a good picture of this weekend. There weren't many normal, not even, there weren't many. I couldn't find any X rays with a normal cecum. Yeah, that's the thing. So the Sikh you can, if you can appreciate here, it's basically the large part, the last part to the bath. You have the sigmoid colon, which is the s shaped that and then the cecum coming in towards the edge as Helen just rightfully said, you can't normally see it on an X ray, which is why I don't have a picture for you because I'm sure someone somewhere has captured it, but we haven't found as of yet. Sugar. But okay. So where are we looking? I'm talking towards the end here. It would be sitting behind. Is it not the connection between the cecum? They're actually both appendix. No, I can't wait. Okay. Point to it going. Can you explain like a secret? Yeah. Uh You know, it's the connection between the small bowel and uh okay, sorry guys, I made a mistake. Technical error. Let's go back. So the cecum, as I still did say, you should normally not see it on an abdominal X ray, but it is the part that connects. I'm getting my anatomy confused. It's the part that connects the small bell entering into the large battle. So up to nine centimeters is permitted is normal. I'm not sure why it's so large. It's just one of those structures that is accepted. Thank you so much. I love. But yeah, pretty much so. Moving back on. Oh no, you don't see that fine. So sigmoid volvulus. So this is our last radiological actually, it's not the last one radiological sign of Volvulus. So the sigmoid colon is the s shaped colon towards the end of the large bowel. And normally, I would say normally you can't really see it unless it's massively distended. So, if you can appreciate here, this is what they call the classic coffee piece side of the sigmoid volvulus. And that's essentially when the sigmoid colon twists in on it, muse entry. So wraps around causing a build up of pressure and obstruction. And if you look, it looks like a coffee bean sign, it looks like a coffee bean, hence why they call it a coffee bean sign. Um This I'll be very honest, this as isn't actually seen as common as people think in clinical practice, but it's just assigned to be aware of and your management of this is what they call a flatus tube. So you insert it into the patient's back passage and that causes a relief of uh hopefully will abate their symptoms. So, moving on to um inflammatory bowel disease. Can anyone tell me what they understand um, inflammatory bowel disease to mean or any conditions that fall under inflammatory bowel disease? Again, please don't worry if you get it wrong, the spaces for learning, I'm just trying to like pull your mind's going to be perfect. So you c stands for ulcerative colitis and Crohns disease is just current disease. Doesn't sound for anything. So, um this is a really beautiful diagram of pass med which usefully summarises the key differences between you see and currents, but then how they can appear. Um Similarly. So I'll give you time to read through this. Um But yeah, this is relevant for our future presentations. Um So yeah, what and people might haven't said anything. OK. So moving on, we have um signs of inflammatory bowel disease. So the first one is um thumb printing. So this this is caused because of the mucosal thickening of the house tre due to inflammation and edema causing them to hear like thumbprints. I actually think this photo is so disgusting, but I I think it shows it quite nicely and as you can see where the arrows are pointing to, they do actually look like thumbs again, it's that repeated inflammation and swelling that's causing um I guess scarring of the large bowel which produces um this thumb printing like appearance. Um And you can generally just see that the abdomen is just very distended. I'm not sure if I go as far to call it regular sign. Um But yeah, pretty much that's what I'm printing looks like. And then moving on, we have lead pipes. So this is what they call featureless colon. So it's the normal loss of house, the loss of normal hospital markings, markings, secondary to chronic colitis. So, chronic, obviously long and ongoing colitis, inflammation of the colon. So, again, if you imagine that repeated um inflammation is going to cause loss to the texture of the large bowel, which leads to this essentially featureless colon. And it kind of looks like a snake in appearance, which is where the red our arrows are integrated. Can everyone see that clearly? Does that make sense? Seem not okay? And then lastly, we have toxic megacolon and this tends to be more associated with alternative colitis. Um And this is colonic dilation without obstruction associated yet with colitis. Um And again, just produces that widespread distended appearance. And you can actually see that it's also quite featureless, but I guess the differentiating feature between say toxic megacolon and the lead pipe is the fact that it's more distended, I would say um some text might say that there are more differences, but on my knowledge, that's, that's what I can tell you. Um So yeah, um I'll let you appreciate that. So, moving onto densities. So now we are oh Yeah. There we go. So now we're at the deep part of the abdomen X um interpretation. So it's very easy to focus on the bowel gas pattern if you're like, oh, there's the abnormality. I'm going to stop looking at the X ray. You really don't want to do that because they could be small abnormalities that you could miss. That could be just as important and contributing to your patient signs and symptoms. So that's why I said here, you want to carefully examine all the bones visible um and all the other um calcification and like dense structures on the X ray. So here we have the lowest ribs here on the top, top right hand side, you have the vertebral columns, specifically the number spine moving into the sacrum and cox. It's, you have the pelvic bones as we identified here earlier, the femoral heads um and the femoral necks. Um and sometimes you can see calcification which will see on future future pictures and these tend to lie either in the bladder um is what they call phleboliths or as renal stones. Um So, yeah, so if anyone is feeling brave, would you like to comment on this X ray? You can either start by saying like, is there any abnormality or um yeah, like what do you see in this X ray? Please tell me rather, it's actually to make it easier. Why don't we say can anyone point to any or point out any density that you can see on this X ray. There's two that I'm thinking of specifically. That is one thing. Yes. Yes, ma'am. Excellent. Not. Is there? That is. Um So that is a dynamic hip screw of a fractured neck, a fema. So that's one density that's metal work. Um And there's another one. Sorry. Silly. Yes. Yeah, definitely. Um So I would say that's probably maybe like a you're a Terek like Calcification. Yeah. Completely correct. OK. Now there's three, sorry, I missed that one. So one more um If we look to the superior aspect of the image, no one has said anything. No, I haven't monitored. Okay. Um Does anyone want to point out be brave? I promise I won't judge you. You can do this way. So we'll have a pointer. Oh So stunning. Costochondral classification. Amazing. Um So as rightly identified here, you can see the lasers for you. You can see calcification forming on the end of the ribs. Um That's sometimes normal in some people, but most patient's you won't see this but yeah, very well identified. That's perfect. So, and this is just to show you some more classification. So this is pointing to um stones like you're a Terek stones um on either side of the psoas muscle from what you can see. And on the second image, does anyone want to have a guess as to what they think this might be? This is not normal to be seen. But if I tell you that your patient was coming in with almost the worst pain they've ever had in their life. Really painful. Had them doubling over. They didn't want to be examined. Yes. Gallstones. I heard some whispers that's gallstones. They don't normally look this pretty. And, um, yeah, just something to be aware. Of course. And does anyone have any idea of what we think this could be? Say that again, Staples from surgery? Excellent brown like bonus brownie points. Do you know what kind of surgery or surgery on? What part of the body would lead to clips in this area? Something to do with appendix that to prepare. That's I'll give you that. That's a good one but not the one I'm thinking of. Is it honey these clips? Um okay, you can have that as well. It could also be a hernia but not the one I'm thinking of. Okay could be these ones. Yeah, but I'll be clipped within. So the thing with the X ray, you can't tell whether not inside or outside. Um Okay if you are all correct. Yeah. Yeah. So the one I was thinking of was fallopian tube clips, you know, when ladies decide like I never would have Children again and they want to get their fallopian tubes kit. I was thinking along these lines. Um Yeah, so this is just to highlight the different classification structures you can see. Um And yeah, this is just the image side by side which produces a really nice um highlighted diagram. Um I really want to plug Radiology Masterclass is an excellent website for understanding radiology. Um I know that when I was struggling in the beginning to identify structures, it really nicely pointed things out. So, um yeah, if you want to go into that website and like further, further your education like good. Uh and then, oh yeah, uh that's a very good question. Um Well, it could maybe not be a fallopian tube thing may be um it could behind your a pet or what was the other one in appendix. But I am wondering now I was an appendix. The reason being a tubal ligation, you only need one clip. That's true. Yeah. So yeah, that's a good question. Actually multiple staples over a wound because obviously we don't, we don't have the skin to look at on the surface rather than inside. Yeah. And that's the thing about abdominal X rays, unlike other imaging modalities, other, other bodies, other parts of the body that your imaging, you usually get to projections. So you can see whether it's like two D or three D with abdomens, you're only looking at once. So as we rightfully identified, you have some confusion as to whether these scripts are inside or outside. So that's an excellent question. Um Any other questions before we move on? Um Yeah. Uh Yeah, I would not be considered what? Okay. That's a good, that's a very good question. Let's get that. So you're saying, why would, can you repeat the question? I'm not sure I understand. Yeah. Yeah. Yeah. Why is that not Rigney? Fine. That's a good point. So, do you know what I mean? Come here. I hope people like and see this. So, are you talking about something like this? Yeah, a good question. I don't have an answer if you have been very um uh like a pneumonia. And that's the only explanation I can think of. I don't know if you have anything. My understanding is regular sign is air. Tissue, air, which is why you see the war very clearly. So sometimes, so you see when you see tissue and air and therefore the outline of the bowel that's normal because we expect there to be involved. But when you see a right there war or tissue and air, that's regular sign because, and that means there's outside of the belt. Um with the thumb printing, you see it clearly because the war has taken, but it doesn't mean that there's a row outside of the wall. So that's why there's a com printing and not regular side. So that's why I'm sending you see it, it's just tissue blended in with what is the rest of maybe the liver as it touches the liver? But you can't see any kind of like uh that is highlighting it because you would expect the shape of the vow to be still be like it was really like like this, it's just not the worst thickened in. So you get the these polyps. Yeah, that's a very good question. Um And any more questions before wo you don't see that um any more questions before we move on, everyone. Okay to move on. Sure. So now we're coming to the final few slides. So going back to the Abdo know Mona, now we're looking at organs. So we identified them um at the very beginning. But again, it's something that you want to pay attention to when you're going through an abdominal X ray. It's uh I'm not going to unless there's something inside the actual organ as we saw with the gallstones, you're not going to be taking an abdomen X ray to look at soft tissue structures. Ideally, you'd get a CT scan or an ultrasound. Um Depending on what the pathology is. So, um I know we've identified them before. So I'm hoping you guys should be experts then. Does anyone want to pick or describe what they think the arrows could be pointing to you? So we'll uh we'll come back to it too. Um Yeah. Go on newly. Oh, sorry. Not a question. Okay. That's fine. That's okay. The top, the top left, your left, your, your left. Yes. Deliver. Yes. Perfect. This is very classical music. Yes. Correct. That is a liver rightly identified. Um Yeah. Uh and people online um feel free to join in. I'm not ignoring you. Sorry, I'm just, yeah, but anyone else want to point out any structures go, yeah. Stunning. Exactly. So, it's muscle. That's a bilateral structure. So, if you see on one side you have more like you'd see on the other side unless it's covered by bowel gas. Oh, yes. Very well done. Um, and there's just two left. Um, I will start by saying the top. that's why it left is confusing, but you're right or my left, the top left, one is not the kidney. So have a think about what you think that could be. Uh Yeah. Can you see it? It's quite, so this is quite a hard one to identify but take a start the brave. Um Again, it's not a structure that you'd often see on an abdominal X ray, but I'm showing you what it looks like so that if you do see it, you can be like, okay, this is what that is. Yes, it is the screen. Great job, Merlin back yourself. It is a spoon. Um So yeah, I mean, is a unilateral structure seen on the left hand side. Um It's not much more to say, but it's kind of it's not unremarkable, but there we are. And lastly, what do we think, what soft tissue structure do we think is going to be sitting in that? It is the bladder? Indeed. Very well done. So nice. So that's just to reiterate having a look at the soft tissue structures um as you can see and I hope you can appreciate that going through an abdominal X ray, there are loads of different components to consider. Um So it is very easy to miss stuff. So by having the structure, it will just solidified that for you. Sorry, that makes this thing has happened again. Just keep your arm right? Stunning. Thank you and people in mind. Um So we'll come back fine and then moving on. So now we are on artifact. So yeah, external objects um and artifact. So using the, this is why I want to get some practice for you guys um of going through that structure and commenting on the images. So, does anyone want to take this one? So my right, your left um and comment on the X ray from beginning to end. You don't have to give me an essay just literally a brief sentence about each um about each line. I know it's feeling brave and I will say that there is an artifact on it. So please include that in your, in your comment and people nine, you can type it out as well. Um The left has a coil, lovely Sandra, very well identified. Um The left one has a coil. So if you can see here, uh that's where abouts it would sit in the uterus. Um Thanks Sandra. We all know what is uh hmm uh It was 100. Oh, it's just when you're in, well, if those addicted to clean the toilet is an, are you gay or? They're the same? They look, you put a com prior to the interview to round device, they should be the same. I don't know how, when there's a couple on like, progesterone. Yeah. Different treatment. So I would say they are, I'll say look the same. Um, yeah, I can't imagine why. Yeah. Well, you're just asking generally like as a contraceptive device. Yeah. Um So yeah, sorry. I know Sandra did say that that is um the coil but does anyone want to just talk through this abdominal X ray using the structure? Uh You don't have to, if you don't want to, we can just move on if you want to move on. Just give me an odd and we'll go on getting some nods. Cool. Fine. Amazing. And then the one on the, let's say the other image. Can anyone tell me what artifact that is? If they can see one? If you can't? That's okay. You can comment on the whole X ray. You can just tell me the abnormality. It's up to you and people online come through. It's Yeah. Okay. Something's wrong with it. There is something wrong with it. Anything say that I'm sorry. Are you uh d are you, would you like to expand them? What the I used? Yeah, please. Olivia. Um Oh maybe. Oh, that's smart. You maybe um Olivia if you could just clarify that. Um So we're looking at uh amazing and it is contraceptive device. Yes. So that was so sorry. It's getting confusing for people like so yeah, that's the contraceptive device and now we're looking at the second um image. So we're looking at this. So that's the coin that they've swallowed, which is rightly identified. So I actually took the sex ray at work. It was in the department. So a six year old kid had I think lost a game with her brother or whatever. So she decided to swallow the coin. Now, coming back to um what we were saying about like why abdominal x rays are indicated. You might think what's the point in taking an X ray of a coin? Like we don't know where it will be, but it's important to have a baseline because as it's moving through the bell, you want to see if she's gonna pass at any point soon or if it's gonna get stuck because you don't want metal like rusting away inside your body and that would be a surgical emergency, should that happen? Um So yeah, that is a coin that kids followed because she lost the game, which is a question. Sorry. Uh um So that's fine. I okay. So there have been x rays that are taken because the IUD has been lost. I actually don't know because that's when I got off Google. So I'm not actually sure why they took it, but sometimes it can just disappear. So, in order to locate it, they'll start by taking an abdominal X ray. Um But yeah, that's a great question. Any other questions before we move on, however you do carry on that, I think you think uh both ish. Uh So where you would put, you won't put it like, it's kind of like where you see it, it's just a bit like that. So when you put an IUD in and then you look at in the front, it's kind of where the bladder should be then, isn't it? Because like the high in it. So therefore that seems like it's in the right place. I've seen how you the uh in extra images. Whereas like anybody at crust that's definitely in the wrong place uh like up somewhere opened up like bowels and you're like not small, right either, but somewhere in the middle, I think it's fine. She just looks that he or she just looks a bit constipated from. Okay. Yeah, that's wrong with that image. Sure. Safe, easy. Sorry. Are you guys? Okay. Any questions? That's right. Okay. So spot the artifacts. Someone said there's some kind of mesh. Great. So people online, sorry, we're looking at this image here, we're looking at image number one. Um So Lily has rightly said there's some kind of mesh. Do you know what kind of mess that might be such? Where do you think that mesh is sitting. What structure generally it's okay. Anyone else is open to the floor, people online, it's open to you as well. I'm not ignoring you guys. Everyone's whispering, someone speak up there. Don't be shy, say no takers. It's okay. So as really right for identified, it is a mess. It's specifically a stem. So that's a colonic stem. Um So as we saw before, you know, the lead pipe cone on where you get like that thinning of the bowel in order to open that up, you'd stick in a stent to just like keep that open. And this second one, so I'll give you a clue if you came to the radiology conference that we had a few weeks ago and you had to play around with some of the toys. One of the device is um kind of depicts what might be going on here. So, yeah, can anyone spot it? We get this off? So people online we're looking at the second image now. Um Can anyone tell me what they see? Can you see it? Yeah. Yeah. So any takers what the artifact might be yesterday and go for it? Okay. So it could be, it is some, some kind of a stent. No, it's not some kind of a cent I can see why you think that location wise. No, no location wise, you're completely correct. That would be in the right place. But this, that's a very good guess. This specific example is not that um that, yeah, I'm trying to think. Okay, I'll give you a clinical clue. So let's say you have Doris, it's always Doris, she's had recurrent DVT S that keep transforming into PS. And so in order to sorry, it's exactly. So uh that's basically correct. That is an IVC filter. So um that's intervene in theory of, you know, cava filter and it's basically deployed through the femoral um theme. So they go in through the, yeah, literally, you have a patient line down in interventional radiology, they take femoral access and basically feed it up. So the reason why it's, it's kind of like that is because it stops the clots from going up and developing into some sort of video problem. Does that make sense? Uh Does that not? Um Yeah, that's a good point. Um They would have to be very like loads and loads and loads and loads and loads of clothes. And then if you imagine that after a while, I think that obviously does actually have some substances on it that cause breakdown of the cots once arrives at the filter. But that's an excellent question. Very logical thinking. Um Yeah, so that's an obvious. Yeah. Yeah. Uh So yeah, that's just a demonstration of what artefacts look like. So now it's a hoot time. So before we get into a hoot, because I think it's only about like six or seven questions we have, we're still running good for time. So it's going to be quite quick. Um Two quick things if any wants me to go over any slide so they can have a look at any images. Let me know now people online as well. Let me know. Sure. Sure. Oh, okay. Are you sure? You said I thought it looked like a whisk thought I was seeing things. Don't worry, I can see what you thought. It looked like a whisk. So you said, can we see the slide before the oh slide? So I'm going back um the slide before the oh I think I'm going to for uh density the slides before. So this is the slide. So I should, hey, I know it's not the slide. Do you mean which side is it that you're talking about this one? The question slide. The wonderful. Okay. No, for this sure. Is there anything I said that you want um explaining um people online, people here are describing food. So if you want to get some food before we start to get your feel for the quiz, let's go. We've got a request over there to go back to the slides where you ask them to go food X ray. Yeah, go back to that. Yeah, I really wanted people to actually go through the structure but no one feels brave enough to. I should have give me access to my heart slides like last week. You sure you get you something to me already did. I, yeah. No, no. Through the, you know, the online kind of the interactive things where, like, things pop up as people kind of filter it in. I think that would have worked better. So maybe we'll keep that the next time. I want to take a picture of it. No problem. Oh, sure. So, you'll get some, besides the list for everyone. We'll get the slides, you can study them later. I know I'm going through it quite quickly. But let me just find which one, which one did you ask them to go over? So that's why I'm hungry may be sick. Possibly this one you wanted to look up uh This one? Yeah, I think actually also while you're eating, sorry. Go on. Oh. Oh, yeah. Yeah. Yeah, we'll do that. I'll let you do that. Yeah. The other thing I just wanted to point out. No, no, I just want to point out with the outdoor X ray. You know how Catherine said in the beginning, um It's like a patient is probably lying down and you're taking it from front to back. Um With this, with the history, obviously, the history that you've given is obvious that that's a coin. But sometimes um even in a chest X ray, you might not know that this is a coin and they have to take it, take one laterally to see whether it is a coin and flat and whether um and say if it was in a chest X ray, whether it's in the trachea or whether it's in a it's esophagus. Um if it's come this far down probably in the esophagus and obviously it fits with the history. So again, with any X rays and imaging clinical correlation advice is what you always say at the end. Um in terms of interpreting the whole thing. Yeah. Do you want me to go from, I'll let Catherine eat. So just go through the abdo extent. So air wise. So looking at where should air b in the bowels, we've got some dots of air here as we can kind of see. Yeah, I don't really see anywhere, anywhere else. You can see the bits of different density, you know, for example, here, um on this side, I'm not sure how big the patient is, but it looks like he he or she might have a bill. Um, you know, might have a large body habit of because like this line here could be like a skin fold. Yeah, like this. Yeah. So it could be like a big large skinfold, which is why there's this like kind of to densities. Um But yeah, nowhere know anywhere else that's fine. Bowels were looking at bowels again position. There's a lot of, so these dots basically. So when um who goes through your large bowel, um bacteria with, within your gut can produce air. So which is actually why you see a lot of poo within the large bowel, you don't see a lot in the middle where you expect the small bowels to be. Um, so that's good. Um, so bowels, why if you kind of, it kind of looks like it's a bit here and there is a bit here. I can't really see the rest, but that's fine. Um, so I would say bowels that's normal size wise if you can't see the thickness, that means it's not distended really. Um And it's just filled with either fluid or liquidy food or solid feces. Um So that's normal. Um And it's likely to be less than the 369 that we talked about um organs and soft tissue eyes. Um I can't, I can't see much at all because it just looks like there's a lot of soft tissue everywhere. Uh which is probably due to the fact that the patient probably has a large body habitats plus just a bit of constipation. Um You can always check that I miss the bones. I miss the bones didn't like bones wise. They both looked both sides of the same idea. Crests look similar. Um This ring, the pelvis ring is quite important to check if, if this is a up the X ray of an elderly women who had a fall, you want to make sure there's no fracture of their hips. Um And if you see, obviously you can't see here, but if you have a uh X ray that kind of shows you the head of the femur as well as important to check for head of female fracture. Um But the ring in terms of a ring, um if you find a fracture in one place, look for the other because the ring doesn't break in one place, it breaks into always. Um But in this case, uh it looks pretty smooth. Um I would say that's like a bit of disjointed Nispel. But I can't, I would just say I can't comment on that because I can't see the rest of it and I can't see the full pubic creams and the rest of it looks fine. So just move on. I did organs, external objects. We commented on the IUD placement which is likely to be in the right place and there's no other external objects or artifacts. Is that clear? Thank you so much. Thank you, Helen. So, um as Helen just rightfully went through it with that, you would conclude your um like reporting by saying um the abnormality detected here is an IED and visualize in the like perfect cavity, but otherwise this X ray is normal in the end. So literally as Helen did it. And what I'd really like to encourage you guys to do is to just go through this acronym or whatever acronym you use and just practice seeing more X rays. Um It does seems wanting at first and you might get frustrated with yourself like why am I like? Why am I struggling with this? But the more you do, the easier it gets with practice. So, yeah, I hope that helps. Thank you so much Helen for doing that. Um Someone down there Olivia, you said, can't it be constipation? It absolutely can be constipation. That is feces backing up in the large battle. Oh, yeah, let's get to see them. Thank you. Sure. So it's kohut time. So the time is now 18 past seven. This session finishes at half seven. So we're going to try and keep this in time. Hopefully we shall. Um I'm gonna share this with you. Oh, no. Ok. They can't see that fine. That's okay. So stop. All right, you have to drag the screen over to that side, right? Sorry guys, we're just gonna do you need to choose the moment. So pick the plane. Mered Gossip. Good. Okay. What? Okay. Okay. So we would like to join you. Don't mean you don't have to join if you want to play, but it might be good for your lungs were very true. We don't force anyone to do it all. It is all consensual here. You don't want to. That's great. Um, and can recheck that people online can see it as well. Uh I need to shrink the acid for, I think it is first come first serve as well. Unfortunately. Well, I was uh, you're fine. Yeah, I thought there was a limit to 10 people. We'll have it. All right. I am gonna, you're funny. Um, cover it. I'm sorry. Amazing. You keep online. Um, so the judges came terrible eater. Okay. So, I'm trying to, what's your name? I don't need to do that. Do you know you just post fall and you should just go. Why am I impressed? It doesn't hurt to be on the screen. So, yeah, this is, that was just kidding. Oh, no, no, no, I don't like that. So just moving out. Yes. Columbian. Yeah. However you do. How'd it go already? Wait online people. Are you ready? Can you talk? Yes or spoken up again. I'm so excited. I mean, if you want to join, I don't want to join getting uh is anyone else for these? You couldn't be a team and feel scared as well. That's fine. Has everyone had a ready to join other in line already? All right. 321. Let's begin. There aren't that many questions. So yeah, just it would be done. Oh, that's just what you said. Oh my God. Just give it any fun. I did the best. Okay. My life. That's one answer. Maybe last few answers. Uh huh. Stunning. Okay, good. So this is just to go through. How do we go? So. Oh, perfect. So um the correct answer is in fact, sorry guys. Can I just get you to listen? The next uh the correct answer is in fact, Supine as we covered in the beginning, I'll show you the side so well done. Lucy, Ruby A DSG Grace. Cool everyone else. Keep up. It's all good. Um Also this is friendly competition. Might I add, please? Let's not cause bites. But yeah. So this is just to reiterate the standard position for a supine abdomen, X ray. It's usually with the patient lying on their back, X rays entering anteriorly, exiting posteriorly and capturing all the structures. Does that make sense to everybody? Fine people online? Does that make sense to you? What fucking no one's saying anything? But I'm going to assume. Yes. Okay. Um So next up, next question, what do you think? What do you think? And it's just awesome. Perfect. OK. So guys, the answer is in fact false. Um Have a look at the leadership, okay. A D coming through. Really Lucy Maisie Grace. Cool. Um Right. So this is just a beautiful diagram to just show where the organs sit. It's not as pretty as the colored image that we had to begin with. Um But as you can see, the gallbladder sits underneath the cap of the liver, essentially, that's actually in the right hypochondriac region. Sorry, guys, can I just get you to listen? That's just in the right hypochondriac region in some patient's, it might be as far over as the epigastric region. But for the most part, it's the right hip or contract region, it's actually the appendix that's, it's um in the right inguinal region and the seeker. So yeah, perfect. So, moving on good. I remember the questions. So that's 67 year old male on care of the elderly. He explains excruciating abdominal pain and appears fluid depleted. What does his abdomen X ray show? So I think that the with every that's and it was fine. Um Phenomenal well done guys. That is good job. That was how excellent A D leelee Amy coming through. Amazing Ruby still on the leaderboard. As I said, it's friendly competition. It doesn't matter. So I don't have a price. I don't have a price to you guys. I'm so sorry. Um You can take some food. Um But yes, so this is Reglas double wall sign. So you guys all got that correct. Excellent. So as I said, but I'm going to keep saying it. So like I want you to go to bed hearing this in your head only belongs in the stomach and the belt anywhere else is abnormal and I hope that you can appreciate the thickened appearance of the soft tissue. So as Helen said earlier, rightfully, it's a soft tissue and that's what gives it that slightly more defined sign. Does that make sense? Uh Yes, because this person has, they must have a lot of air inside their bowel because of perforation. Think about the line down actually, where does the air rise to the top of the abdomen? So it won't actually just like on the space around the bowels, actually, all of it would have might be here. So I feel like it's a bit hazy as well. Yeah. The quality is rubbish. So that's because it's be obscured by all the air. So, yeah. Yeah. Cool. So, next we have two or four, so a six year old female playing a coin all the time. I wound up coining a coin game with her brother. Lost the game and decided to swallow. His coin is an abdominal X ray indicator entry of us and yet so much is pregnant again. Oh, that's uh I said himself uh I read the big gun. That was actually, do you know what I'm gonna take full responsibility? That was actually my fault. I should just let you read it. Um But basically the whole point of this, sorry guys, the whole point of this was to just reiterate like when we take abdominal x rays and when we don't um with any imaging investigation, as I said at the beginning, if you're going to order an investigation, you need to be ready to interpret it. You need to, you need to know what you're looking for. We can't call radiology and just be like, oh, I want an absolute expert. They're going to be like why you need a clinical reason. So I'm sorry, I kind of room that one for you guys, but here we are here, we are so okay. What? Four turn around. So A D Maisie and Ella are taking top three with Amy and harsher coming through. It's looking a bit tense, fine. Um And that's all I had to say. It is indicated. As I said, any imaging investigation, you get be prepared to interpreter um and know what you're looking for and then I'll just let you breathe. I wouldn't build this one. We can, we can take a friend. I'm so sorry about this one, but I had to include it. So I can see actually, can I see what you said? Thumb printing, maybe let's go through it. Um So, oh, nothing changed. Wow, well done. Okay. So it is in fact normal. So sorry. But the reason I included this was because not every imaging investigation you come up with is going to yield something medical like medical school like citric you that um if someone has a problem, you're going to get an image and it's going to show you what's going on. No, sometimes you get an image and you're like, I don't know what I'm looking at and it is in fact normal. Um And with the symptoms that he was experiencing it, it could be a new onset of ulcerative colitis and it might not be yielding abdominal changes at the moment. So I had to agree this just to show you that sometimes things do come back normal. Um And that's just the way it goes. I'm so sorry. So many differentials for central abdominal. It's such a very presentation. So yeah. Yeah. So yeah. So yeah, I'm so sorry. But I hope that can take you. I hope you can remember the pain of losing this question and just remembering that sometimes they are just normal. I think this might be the penultimate question. I think it's the uh next will be the explanation. Sure. 2012. Oh, a lot of people to sorry. Okay. Sorry. Mhm. Uh Funny. Well done guys. So yeah, that is in fact the football sign um caused by necrotizing Antara colitis. So yeah, this, as I said earlier, this tends to be a condition associated with me in eight. So newborn babies. Um and in order to manage that it's no by mouth IV fluids and TPN which is essentially feeding through their summer TPM. Total parenteral, parenteral country. Like I think it's in the peritoneum but um and antibiotics to stabilize them. It is a surgical emergency. So if you ever see this call for your senior and call the surgeons and, and call it a day. Um But yeah, I believe that is the end of the week quiz. Um So now we have the podium. I have no prizes but this can be your prize uh place well done here is uh hold on. Amazing who was Mimsy all amazing. And in France place we have. Yeah. Uh No, no, no. It's a very well deserved win. We have no cheap. It's been very well done guys until all of you. I hope you enjoy it. But yeah, very well done. Yeah. What's next? So I'm just gonna come. Okay. Let's come back to the slides. So how do I left? Left, left, left. You should see your mouth yet. Okay. Can you click on that one? Yeah, perfect. So uh okay, fine. So that's the end of commute. So this is just a summary slide. So just to reiterate the abdomen, X rays are good for ruling out destruction. They're good for an initial uh screening tool. It's good for looking at signs of perforation as we brighten identified pneumoperitoneum. Uh As I said, you're getting any investigation, be prepared to interpret it. If you don't know what you're looking for, don't bother getting it. Um Finally, you might want more detail and you get a CT scan and lastly stick to a structure. And I recommend radiology masters cost and radio pedia is another good one to just practice going through the abdominal X ray structure. And as I said, we don't fall anyone to do anything here. So if you don't like Abdo X, that's okay if it works for you and practice it. Um So thank you guys so much for listening. If it's okay with you, can I just get you to fill out a quick feedback form just so we can help so it can help us improve like further sessions. And of course, like me teaching as an educator. So yeah, I hope you enjoyed and if I wanna has any questions I'll be behind. So, yeah, come and ask. Thanks. Thanks guys. Um So yeah, and people online um I hope you can see all of this too if you could fill out the feedback form. I hope it was bearable for you if you don't hear about something. Yeah. Yeah. Thank you so much guys. I'm so tired. Oh.