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Okay, great. So I think that's everyone back. Hopefully. Um So next we've got Sandra who is an S T five and radiology. She's going to be going through the gastrointestinal radiology. She's got a special interest in pet and nuclear medicine actually, but I'm looking forward to today's talk. Thank you. Mm mhm That's crazy. So hopefully everyone can see that slide. Sorry, that slide. Awesome. So um thank you trying to get, I'm just gonna start fiddling. Hi, I'm Sandra. I'm an S T five radiology training from how um very happy to come back um to present uh my G I talk um for the S I T. So we're just gonna go over the surgical abdomen. CT basic some tips and tricks. I know there's a wide variety in terms of levels of training in the audience. Um from previous feedbacks. It's always been a good mixture of foundation trainings, cold medical trainees and surgical distress. Um So I'm going to try and show as many cases as possible the most common things that you would see. Um But we're just gonna go over very minor technical issues in terms of not technical, but in terms of what a CT protocol is and what we expect um when it comes to a clinical requests very briefly. Um So objectives of this presentation, we're going to learn the different CT protocols. You'll be thankful to know that there is very little that's essentially four um that we need to know. Um I'm gonna interpret a CT abdominal scan and the common acute abdominal findings that you expect to see on court. Hopefully, by the end of this presentation, everyone will be a bit more comfortable looking at C T S on their own before waiting for the radiology report. Um For anyone who's never ever seen any form of radiological imaging, especially cross sectional, we essentially have free views, which is the XL, which is when we sort of basically slice through the patient um from the top to bottom, we got a sagittal which from the side view and corona from the frontal view. And obviously, this is very important as thankfully um as helpfully highlighted by Princely William. Um it's very difficult to look at pathology on a single um view. Uh Usually with these free views, you can more or less get a diagnosis, uh more accurate form. So lots of um I'm sure this feeling has not changed very much. Lots of junior trainees, even some surgical trainees as well usually have a sense of dread when they're asked to discuss with radiology in terms of clinical requests and to be honest, um as long as you have the next four main questions in mind, it really shouldn't be a horrifying experience in, in my opinion. Um This is more or less what I look like on call on the weekend. So just like share. So this is a very quick example of a clinical request essentially when I'm on call. Oh, I want to know from the clinicians when they're referring a patient for a CT. Um it's basically the age and the agenda specifically, you know, if they're female male because I'm worried about pregnancies and, um, you know, have they done a pregnancy test or, you know, if there's had any previous past surgical history that's relevant, don't mention everything. Only the relevant things such as if they've had a colectomy for, you know, bowel resection for primary malignancies or whatever, those are all very relevant findings if there's any recent operations. And I appreciate that we don't always have those information at hand, but it would be nice if you could clarify because most of the time we get a request that says, you know, acute abdominal pain pre preparation, which is fair enough. But then when you look into the scan, they've had, you know, anastomosis sites here and then they obviously had lots of surgeries. It does make this, uh, report a bit more difficult because essentially if you don't know what sort of, uh surgery they've had previously, it's very hard to sort of come to a diagnosis. Um So basically help us to help you. Um Most of the time if this happens anyway, I'll be calling the referring clinicians to have a discussion because you know, the term clinical correlation is not the most helpful. And I appreciate that. Um also clinical presentation. Um If the patient's acutely unwell unstable, this takes precedent, obviously, and it's very helpful if you highlight that at the beginning of the request. If you say, you know, you've got patient recess, the moment you say resource, my sort of alert bells are going. Um and you said, tell me that he's septic or, you know, is hypertensive parity genetic. We don't know what's wrong. There is very little that I'm going to ask you in terms of, you know, at that point, if they're so unwell, I don't really care about the renal function because, you know, it's either the patient has a scan and it's taken to theater for a laparotomy or, you know, if they've got AKI stage two fair enough, but if they're going to die, then, you know, that takes precedent. So, um clinical judgment is very important and, you know, telling us the blood as well, if the blood's are absolutely fine, then we're less likely thinking of an effective or inflammatory sort of process. It could be like a ovarian torsion, for example, it could be, you know, if the patient's very young, it could be cancer, sorry, if the patient's very elderly, it could be cancer, you know, that won't show as, you know, raised inflammatory markers. So all this sort of paints a picture in my mind and it's very helpful when you have these at hand. Um Right. So, very quickly we're going to move on to CT protocols, like I said, essentially there is four. Um So the first one, so this is an actual ct um abdomen, pelvis, single slice is the first one is a noncontrast study. Hopefully everyone's aware and how I can tell is that because I can't see anything in the hepatic veins. I can't see the cortex of the kidneys. I can't see, I can't differentiate between the medulla and the cortex of the kidneys. I mean, and as well as um like this bits here that is it bow is that stomach is that pancreas is basically very difficult to tell. Which is why a noncontrast study is always the last resort. Usually, if patient have difficult IV access, we can do a noncontrast study but bear in mind it's a last resort because we get this sort of pictures is very difficult. Yes, we can tell you if there's obstruction, we can't tell you probably where the obstruction is or what's causing it like a cancer. We can tell you if there's free air, we can tell you if there's free fluid, but that's essentially it. So that's why sometimes we, we try and um advocate for IV access. Um the second image is an arterial phase. And how I can tell is because immediately you can see the, so this is the abdominal iota and it's well pacified with contrast. So arterial phase is typically um you give the injection of IV contrast um and it's about 2025 seconds, 20 to 25 seconds. And again, you can see the kidney is much better straight away. I can see the the vessels much better. You know, this is probably gonna be small bowel, this is stomach. So comparing that with the first image and the 2nd and 3rd image, sorry, it's gonna be a portal venous study. And again, how can I tell? Because now we've got the portal vein that's more well pacified, portal vein, portal venous study. Um the iota is less uh well pacified. Hopefully you can see my arrow. I'm not sure if you can see my arrow. Um And then the lastly, we have the delayed imaging, which is usually depending on your trust attached to 15 minute delayed study and how I know this is because you can see apologies. Have I done? Uh one second? Sorry, can I just close it? Yeah. So on the fourth image, you can see there is contrast within the renal pelvis and ureters. So this is um delayed study and that's ideal for looking at your phileo malignancies and you know, in traumatic settings, if they've had pelvic fractures and you're worried about your injury. This will be ideal studies. But typically the most common study acutely on call is supposed to be in a study which is number three. Um and portal venous is usually about 75 seconds after the injection. So very quickly over oral contrast because I know some junior colleagues are not very familiar with this. Um So in my trust, we give me peck 3 50 it's a water soluble oral contrast and that's important because um you know, if you're creating perforation or anesthesia Matic leaks, this is very helpful because essentially you will get contrast going through the peritoneum. And if it wasn't water soluble, you'd be at risk of peritonitis, which is obviously very bad. Um So routine preps in my hospital, you give 25 mills of all my peg in 800 mils of water and you basically um try and get the patient to drink. Bear in mind, you know, if they've got a domino pain, they're probably a bit nauseous a bit. Um vomiting a fair bit as well. So we try and encourage them to have maybe a cup every five minute intervals like we don't expect them to down the whole 800 but you know, a little bit will be helpful. Um And then we scan the patient about an hour later. Um indications are contrast typically on call. You don't give our contrast and we're just going to highlight the reasons when you would give our contrast So, first of all, um, like I said, if the patient was recent post up and they've had an Estamos Iss, um, of the bow or whatever, um, it can be quite tricky to see on CT if there is a leak. And the best thing to do is to give our contrast. And basically, we're waiting for the oral contrast to pass to that bit of bow. And if there is a leak, then, you know, naturally it will be leaking into the peritoneum and it's quite straightforward. Um However, in the absence of our contrast, you can sort of still, you will still be able to tell if there is a leak, but it's a bit more tricky. Basically, all the signs that you have is the degree of fat stranding. If there was free fluid in that region, if there was free gas in that region, again, these are not definitive, that's which is why oral contrast is better. But, you know, sometimes the patient is so unwell and unstable, then we just can't wait for the oral contrast to go through. Um The second thing is fistula formations. If the patient is very skinny, it's, it can be a nightmare trying to um uh separate about small bowel from colon or, you know, bladder uh so oral contrast, but again, it makes life a bit easier when you're trying to assess this region's um another reason to give our contrast is if the patient has difficult um had difficult veins or IV access. Um Typically IVD us, for example, or patient's who are hypertensive and basically shut down peripherally. Um Again, this is not very common. Um and other reasons. So, like some of the papers that I've highlighted in the slide at the bottom of the slide, um oncological reasons. So you give or contrast, some papers say that it's better to, it's, it makes it easier to look for peritoneal disease like a mental caking. However, I have seen a mental kicking slash peritoneal disease with blood or contra. So it's not essential. Um So essentially, the main reason why you would do or give or contrast is if you're creating an anastomotic leak, in my opinion. Um This is why I do my practice anyway, uh contraindications to our contrast, obviously, if they've had any allergic reactions, um and very important to note, you never give all contrast if you're suspecting about ischemia or a G I bleed. And I'm going to highlight in the cases following why this is the case and obviously severe renal impairment IV contrast, we give only paid 3 50 in my hospital um arterial phase studies. Um So a lot of times you might get a bit of problem, you might get a bit of resistance from radiology, registrars or consultants because of the size of the cannula. And the reason why this is is because for an arterial phase study, it has the rate of the contrast has to go at a specific rate, essentially has to go at four meals per second, which is quite fast. So you can't really fit that through like a blue or pink cannula. Um I mean, you can, but you won't get a very nice arterial phase study, which is why we try and advocate for a large ball green eat engaged cannula. Um This will apply to CT PA studies, um CT IOTA studies uh Intercranial NGOS, basically anything that requires an arterial phase study um for the portal venous studies. Thankfully, a pink cannula is fine, which is about 20 gauge cannulas. We give that about 2 to 3 meals per second, much lower. Um In very exceptional cases, you can give it via C V line, central line. Um Same reason with the arterial phase because it goes at such a high rate. We can't get it by a central line because it basically will just erupt and explode, which apparently has happened in some trust before. Um So it's basically no go zone unless it's a portal venous study. But even in those scenarios, you will need to have discussions with the radiology consultant slash registrar to clarify that we've exhausted all other options. Um And uh so next is a um so this is a real case that I had on call and just again, highlights the difference between the CT protocol. So again, Axio a CT of the abdomen pelvis. So this one is a noncontrast study. What our clues? Well, we can't differentiate like this is the kidney but at least represent simple says most likely. But you know, on this single slice, are you sure it could not be bow? Um I can't really see the hepatic veins very well. The iota is not pacified, this sort of crescent eric hyperdensity that's calcification. Um So this is a noncontrast study. You're very sure of that. Next we give um arterial, we give contrast in the arterial phase. How do we know because the iota is well pacified, you can also see the cortex and the middle on the kidneys very well. So this is a contrast enhanced study is either going to be an arterial portal venous or delayed. And because the iota is our pacified, this is an arterial phase and straight away you can see as well that these are simple cyst. So it much makes it much easier to appreciate. And the third images a portal venous study. And again, how do I know this? Because you can see contrast within the hepatic veins um as well as the portal vein, which I don't think I've included in the slice, but the IOTA is not as bright compared to the arterial phase, which hopefully everyone can appreciate. So, these are the three main um CD protocols. Um Now we're gonna go to cases um try and make things a bit more interactive. So, um so all these cases are from radio pedia. Unfortunately, I was hoping to share some cases by uh my packs workstation, but because of firewalls and whatever, there's just been a bit difficult. So basically how our approach A CT um this is how our approach A CT basically on court. So we have an axle CT Abdel Pelvis. Um It's contrast enhance. How can I tell again, are indicators. We can see contrast in the hepatic veins, we can see the kidneys cortex, medulla very well. The iota is not very bright. So this is gonna be a part of in a study which is our most common study. If you ever have to guess, you know, if you put on the spot by consulted guess portal venous. Um So, uh so this essentially, I just wanted to show you a normal CT first before we go into the pathology because knowing normal is very, very important. Um just bear in mind this patient has had oral contrast as well and that's why it looks like. And you can imagine if you were suspecting a bleed in like the small bowel, for example, there is no way you'll be able to differentiate that from oral contrast because it's just completely pacified with from the oral contrast. So that's why we never give it. Um if you creep bleed or bowel ischemia, and I've got a few cases to show up, but I just wanted to highlight this is normal bubble, um normal colon normal's mobile. Um In fact, just remember fat is your friend in CT. Um So moving on to the next case of first pathological case. Um So again, we have an axle ct contrast enhanced, we've got several simple cysts in the kidney uh in the liver, which is absolutely fine. So this patient was 30 years old with um right at force a pain, um feverish septic, unwell. So straight away before even um looking at the CT your, your mind goes for um potential differentials and write that for the pain, a young person fever, you have to look for the appendix. Um actually sorry on that normal scan. I'm just going to show you the normal appendix. So right there for so it comes off the cecum. So how it describes a short blind ending tubular structure, which is this here. Hopefully everyone can see my mouse as well. It's not the standard, it's got some gas which is normal. There's the fat around its pristine, there's no fat stranding, there's no edema. So this is a normal appendix and it's coming off the cecum. They're happy looking at this study. Now, hopefully everyone can. So this is sick. Um Before you even look at this before you even look at that, you can see that it's fat stranding around everywhere. So this is abnormal, this is normal, this is abnormal. Um And you follow it, you've got a grossly thicken appendix. Um There's a short tube a little blind ending structure. This is the distal end. If you follow it, it's got some hyperdense material within it most likely in appendical. If, um, if you keep following it, there's another one there just at the origin site um as it joins the cecum. So this is acute appendicitis with panic lifts. Um And if you're a good radiologist, you're gonna also be looking for complications after you found the pathology is, isn't complicated or uncomplicated appendicitis. What I mean by that is that, is there a perforation? Is there a um collection and how we differentiate between collection and free fluid? I will go into the men in my slides and a bit. But basically this is someone with acute uncomplicated appendicitis and you know, such go for and the rest of the abdomen is absolutely fine. She's got a intro you're trying to buy some situa, which is what that looks like there. But yeah, so that's our first case, acute appendicitis. Um um Moving on to a third case, I just bear in mind. I know there's quite a few cases. So I just want to make sure we're on track. Okay. So next case, um so again, ct abdomen, pelvis, with contrast, we've got multiple stones in the thin walled gall bladder. Um And you know, there's no evidence of blurry doctor location that's fine. Again, thin wall, the fat around the gallbladder is pristine. So it's fine, we're happy. So this patient was 50 year old with left let force of pain, feverish septic, unwell. Um And again, when you scroll through the scam, the first thing you're gonna see is fat stranding. Remember fat is your friend on CT. Um Let me just and blow it up a little bit. Never one can I assume in. No, no, sorry. Um So uh hopefully everyone can see the tiny outpouchings in the, so this is a signal colon. So uh this is the descending colon and you can see outpouchings again. And so up here, this is mid descending colon around surrounding fat, normal pristine, no fat stranding. As we follow it down over here, you get some fat stranding here. The uh sigmoid colon, proximate smoke colon is also quite a thick walled. Um Essentially this is acute diverticulitis of the sigmoid colon. Um Again, we're looking for any complex. Once you've assessed the primary diagnosis, you're gonna look for complications, any evidence of perforation, uh free fluid uh collections, there is none. So this is a case of acute uncomplicated diverticulitis of the proximal sigmoid. Um I don't think there's typically this is just managed conservatively. Um unless it was a perforation of complications, the surgeons might, if I think in my opinion, they don't really do anything with this case. Um and say anything else on this. Um No, okay. Hopefully, that makes sense. Um moving on to the next case. So um this is a ct abdomen, pelvis for some reason, they've limited it. Um, they've only included the upper abdomen and not the full pelvis. That's extent of it. But, you know, that's fine because we can see the clear abnormality. Hopefully everyone can see this. So, comparing it with the previous CT, I know it's a bit small. This is normal gallbladder, thin wall fat around it is fine. Yes, there's some stones but, you know, it's not causing any problems Going to this case, there is fat stranding, the gallbladder wall is thicken. Um Additionally, there is pericholecystic um fluid. Um it's got a peripheral rim of enhancement. So it's actually a localized, is actually a collection, um localized collection. And why that's relevant is because typically, if you get a bit of free fluid, nobody really touches the patient, they just leave it as it is. But if the fluid, you know, becomes stagnant, it becomes infected. That's when the they need to discuss with the I R team and get a, a drain put in. Basically. So this patient, I know it's quite pixelated. But um actually this patient actually had a localized perforation in the gallbladder wall. I don't know it's seen very well, but basically, you can see this. So this is normal, I mean, this is a thick wall and then you get a defect, thick wall and there's a defect here. So this is a patient with localized um perforation of a complicated cholecystitis with a associated pericholecystic fact, uh sorry, pericholecystic localized collection, um, and a perforation. So this is someone who presumably they, if they were not fit for surgery, you could put a college to stormy, um, draining and, you know, watch and wait and see how the patient goes. Um, typically the patient's tend to be quite elderly and quite frail. So, surgical options are, are not ideal. Um, but yeah, so these are the, what probably make up the bulk of um acute on call cases. Um So we've done appendicitis diverticulitis college societies um and moving on to the next case, right. So this is again, it's contrast enhanced ct portal venous face, you can see um the hepatic veins or pacified very well part of a uh report obey an IVC and IOTA are similar than similar density. So this is a portal venous faces supposed to arterial face. The other striking abnormality is that there is multiple, the standard uh predominately fluid filled small bowel loops. The patient also has an N G tube which is helping with the decompression, it's stopping just there. So that's fine. So whenever you see small bowel obstruction, um the rule of firm that I I learned in medical school was 36 and nine. So if the small bowel is more than three centimeters dilated, concerned about obstruction, um six centimeters for colon, nine centimeters for the cecum and I still use that um parameter in my daily practice. Now, um for those who are more familiar with small bowel obstructions. The most common cost tends to be adhesions, adhesional. Um Alternatively, you can also be due to um hernias causing, you know, strangulations and things. For this particular case, it can be a bit of a nightmare trying to follow the bow. Um Either you start from the top end, so stomach uh and then approximately duodenum and then crossing the D J Fletcher somewhere here but and then becomes the judging. Um And then it becomes very difficult to follow it, especially if they're very skinny. Patient's another thing you can do is go from the back end. So, Rectum's sigmoid um sending colon um in the interest of time. I'm just going to tell you that the patient's transition point was here. So you can see the standards is still small bowel with abroad tapering. There's no obvious cause it just sort of tapers down. Um which is very, it's very typical of adhesions. Um Presumably this patient had prior surgery. I think the clinical history was that she had prior gynecological surgery, not sure what, but basically it was occasional small bowel obstruction. Um So the terminal I'll um distilled to that site was collapsed. Um But yeah, basically, this was the site of the transition point. So this was acute mechanical, so, mobile obstruction, adhesional, again, complications, there was no evidence of perforation, there was no evidence of local localized collections. There was no um bowel ischemia. Um And bowel ischemia is a uh I've got a slide about about the scheme and a bit, but basically, I just want you to remember that this is normal bowel wall, this is not thicken, this is enhancing. Um, and this is normal bowel wall. Okay. Um The reason why I'm saying that is because I've got a few cases that shows, you know, bowel wall enhancement and it's very striking. So just be familiar with what is normal first. So this was small bowel obstruction with adhesions. Um Next case, I'm aware of, I'm going a bit too quickly. Please feel free. You can ask me questions at the end. Um But yeah, I just want to make sure I sure you guys as many cases as possible. So this was another ct abdomen, pelvis, um got some gallstones, the thin walled gallbladder, you don't care. And then we've got N G T going through a collapse stomach, we don't care. So this patient had um abdominal pain. So just scrolling through, we can see that there is some distention of the seeker and ascending colon as well as the transverse colon. Uh And as we follow the descending call on, so follow it, follow it, follow it. So that's all fine. 05 and then we hit this point. So this hopefully everyone can appreciate this enhancing intraluminal mass lesion um in the sigmoid colon. In fact, it's causing a stricture. That's why you're getting proximal delectation. How I know, this is because this still to this side, the bow is collapsed, directive is collapsed. It's not very, there's nothing in it. But, yeah, so basically this is, um, large bowel, uh, obstruction, secondary to a malignant stricture. Um, it can be one of two things. Actually, it could be, so, essentially is because of a stricture, but it could be malignant or it could be inflammatory and essentially, um, sign, it can be quite difficult to differentiate between these two on CT. So typically, you know, the patient's going to have a colonoscopy regardless. Um just to have a look and get a histological sample. Um typically, if it's malignant, it's gonna be most commonly primary um chronic adenocarcinoma that cause stricturing and proximity irritation, enhance full of obstruction. If it's an inflammatory stricture, you're thinking more along the lines of diabetic losis, that's the most common um cause. But this patient doesn't very convincingly have any evidence of diverticular disease. Therefore, I'm leaning more towards malignancy. Also, he was elderly, he had weight loss, you know. So um they eventually did do a coloscopy and this was proven to be a, a carcinoma and he had receptions. Um But yeah, so that's large bow moving on another patient. Sometimes this is all the clinical information that we have Abdel pains, queries, mobile obstruction. So whatever extra things that you guys can give us is very helpful. Um You know, so this is a portal venous study immediately we can see there's multiple distended, um, large bowel loops. Again, this patient has to receive or contrast and we can see that all within the small bowel. How do I know there's a small bowel because you have the bubble account Aventis, which is the line that crosses, um, both borders and you know, if there's any adult go back to tracing the, the colon's. Um, so you can do front and back and personally and for the back end because it makes it's just shorter to follow. Um So rectum sigmoid collapse, it's collapsed following it sigma. And then it looks a bit funny here because it's sort of got a twisting motion. Um If I can't convince you, let me show you on the corona. So basically starting from the bottom. So, um so this was rectum and then you got sick point going up here six point and then can you see it sort of twist like a swirling appearance? That's a classical term that we use in radiology. Um There's a swelling appearances and it sort of wraps around itself and then it comes up here and then you get proximal delectation. Um And this is basically sigmoid volvulus. Um when you get swelling in the midcentury with about, about adaptation approximately. And also, I think everyone's more familiar with the corona view where we get the kidney bean or coffee bean appearance of sigmoid volvulus. Um If you ever get stuck in a question with a Viber or with a consultant. And they'll ask you is the sigmoid or single volvulus because that's the main two. That's the only two volvulus aside from Gastric Marvelous, which, but that's a different story. Um Sigma Valve, this is way more common. Um Essentially with sigmoid volvulus arises from the pelvis because obviously the sick point and it extends towards the um right upper quadrant. Usually I know this one shows the left upper quadrant, but, you know, typically text book tells you it goes the right upper quadrant. Um The second thing is that it's, it loses its um but normal bowel castration. So it's a hostile whereas a Sikh evolve, elicit, maintains it house, maintains the whole stations. Um And yeah, basically, that's how you can differentiate between the two. But if in doubt, sigma marvelous way more common. Um And the other thing is typically depending on the trust that you work for. Um Normally, if they're creating a sigmoid volvulus, they just do an abdominal X ray. Um because the patient just if it's confirmed an X ray, then the patient goes for has a fatalist tube inserted, decompressed and then, you know, either repeat the test, uh sorry, repeat that Domino X ray if they are persistently unwell or has still, still has pain, but if the symptoms usually resolve by then, then that's the end of it. Um So I'm not sure why this patient had CT maybe presumably they did the latest tube and he was still unwell. But yeah, there's no harm in doing a CT to look for any evidence of ischemia twisting. Um, oh, and the other thing is just bear in mind as well on the Excel. Um, the, the bowel wall is still not thicken. Okay. This is just normal. Remember the devotee lightest one that was very thicken. This is still very thin. So this is normal and that's, yeah, not concerning. Um Hopefully everyone is still with me. I can't tell, feel free to write stuff in the chat because I think I can see the chat if there's any questions or if you want me to repeat stuff um uh moving on. Um So this is a portal venous study, however, it's been saved on the bone windows. Um Just so you can either put bone or lung windows basically when you're trying to look for free air and you know, hopefully everyone can appreciate. There are multiple extra Luminal blobs of free gas seen the upper abdomen. Um It's a larger weapon there. Typically, the rule of thumb is that if you get um free gas in the abdomen and it's a small volume, you're looking at upper gi perforation because if it's a lower gi perforation, it will be a larger volume and they'll be a lot more fluid. Um Just because like if you think of like colon, for example, ruptures where it's like upper gi perforation like the duodenum, you know, duodenal ulcer perforation was common or, um, you tend to get sort of disappearance. So, you know, just by looking at this study without looking at clinical history, um I would have a hunch my beds and said this is probably an upper gi Perth most likely in the duodenum. Um, so let's try, make our life easier and try and localize the side of the perforation on ct, all you can see is a defect just like that college cystitis case. You're looking, you need to trace along the walls of the um the organ in question. And if there's a defect, then there's a perf this one, I can't remember. Basically, I think we struggle to find the perforation but actually know is there. So hopefully everyone can see my mouse. Um So we got about Wahba, Wahba and then you got gas. This doesn't seem to be in the lumen. This is going to be outside the lumen. So this is probably the site of the perforation. Sometimes it's tricky to see, but you know, this patient went for operation and it was confirmed it was in the proximal duodenum. And then if you clarify the history bit further, they had a history of um NSAID abuse or, you know, they've been pain for a while and they just kept taking an six, which is obviously a risk factor. Um The other thing as well was there's a bit of free fluid. Um But no localized collection, small right side of your effusion um and a small hiatus, hernia. Um Yeah. So moving on. So bright pr bleeding has warfarin for mechanical valve. So if for those who are not familiar with radio pedia is a, is a immensely useful resource that everyone in the radiology still uses, you know, even radiology consultants uses it. It's completely free. You have all these cases if you want to sort of um buff up your CT knowledge or even MRI X ray ultrasound, whatever. Um As long as it's some sort of radiological imaging, it will be found on radio pedia and it's all free. So this patient from the clinical history, um it sounds like they were looking for a bleed straight away. If you're looking for a bleed, the patient will get a triple face CT. Um You know, if it's curry bleed in the wherever part of the body to get a triple face CT because one, this is a non control. So the first one we're looking for is a noncontrast because essentially all we're looking for with a bleed is um contrast, extra visitation. So I'm just gonna make life easier and just show you where the blood was. So on the arterial face, it was in the colon. There was uh sorry, I had the cases, but there's been so many cases. Yeah. So hopefully everyone can appreciate this hyperdensity within the distal descending colon. Um If you look at it on the X L sorry, on the non contrast, it's not there. So this is why noncontrast is so important because sometimes you can get ingested material that's hyperdense for whatever reason. Um Okay. Um And you know, is this, you can't tell if this is bleed or is this from ingested material or, you know, for whatever reason, this classification, I mean, it's very odd but you know, potentially. So that's why noncontrast helpful because it's not there on Hong Kong. So it it can't be anything else but hemorrhage. So we do the arterial phase is there and then we do the portal venous face because remember, arterial phase is done at 25 seconds. Portal venous is done at 75 seconds. So essentially you're taking a snapshot at different periods of time. So if it's an active gate, it will increase in volume because it's actively bleeding. Um And basically this was the case. So this portal venous, there is quite a fair bit of hemorrhage really in the descending colon. Also noticed there's multiple outpouchings in in keeping with diverticular disease. Um diverticulitis, sorry, diverticular disease is the most common cause of P R bleeding, uh clonic bleeding. Um It's not actually diverticulitis, which is interesting, but yeah, diverticular disease, you know, you don't have to have inflammation and it can just bleed. Um The other thing you to make sure is that, you know, make sure it's not like a cancer, something that's sort of eroding through the walls and vessels and causing a bleed. It's very rare but not impossible. Um So yeah, this was someone with acute, sorry um diabetic color disease with acute gi bleeding. Um What you do in my trust you because we are a tertiary center, you refer the patient on to ir the IR vascular team and then they will try and see there's a site for embolization, you know, with the angiograms and whatnot. Um But yeah, so this was a nice case of a gi blade. Um other things on call left line pain. Um So this one, hopefully everyone can appreciate what kind of protocol this is, this is a non contrast because I can't see the cortex, I can't see the medulla on the kidneys. Um I can't see the hepatic veins. Um So on this. So this essentially, this was a C T K U B. Um So we got a large hiatal hernia that's fine and the patient had left sided loin pains, you know, typical history, positive urine dip, a septic um acute onset pain, Ukraine Reno souls basically, right. Um The one thing I was going to say as well is that when I said fat is your friend. That's true and says that whenever you see fat stranding surrounding a visceral organ, be concerned that there is something going on pathologically. However, this is not the case for paran ethic fat stranding because you can get non specific paran ethic fat stranding, but it tends to be bilateral. Um So everything obviously taken with context. So if you see on this view, the left side has a fair bit more strengthening, the right side has a little bit, but the left side significantly, a lot more. Uh We've got a left renal cyst which we don't care. So straight away, your eyes should be glued to the left kidney wondering why is this kidney having more fat stranding on the right? Um Yes, I know that it can be a non specific finding. But let's see if there's anything that I can see that's causing a problem in this kidney. So we got the left ureter here and this is a fairly big ureter. How can I tell? Let's compare with the right side, which is normal. So that is the right ureter. It's tiny. Sometimes this patient has a fair bit of abdominal fat. So you can see the, the ureters. But typically, if you can't see the ureters, that's a good sign because it tends to be collapsed. You know, the only reason you would see if it's dilated like a hydro your it is because there's an obstructive cause either a stone or cancer. Um or yeah, cancer. So then you can follow it all the way and that's where it joins into the bladder. So that's absolutely fine. Now, let's follow the left side which the pathological side. So big straightaway, left hydroureter follow it, follow it. And there's also fat stranding surrounding that ureter, follow it. And there you go, there is an obstructive calculus. This is probably four millimeters. So my report will say four millimeter left proximal ureteric obstructive calculus with causing a degree of hydronephrosis iss very mild, I would say um and distill to it, I sort of lose it the ureter. But again, you know, that's absolutely normal to lose the ureter. Sometimes you can get it in the better ureteric junction, which is about here. So that's the ureter drawing in the bladder. Again, that's normal, that's fine. So this was a case of um you know, obstructive, you know, track calculi, which is fairly common in someone of abdominal pain. Again, we have multiple um sigmoid diverticular disease. Again, fat is your friend. There's no facts running around it. So this is just, you know, there's no acute inflammation, we're not worried about that. That's not the cause of the pain. Very commonly left side of pain, right side the pain. However, commenting are common appendicitis, diverticulitis, cholangitis, um cholecystitis as well, um obstructive renal calculi. So this one's just a corona view that just nicely highlights this is a very dilated reno um sorry, left ureter. And that's the stone. Typically, they say if it's more than four, less than four millimeters, it will pass on its own. That's what urology um usually says. However, it's bigger than four millimeters, then they might consider lithotripsy. Um Also if there's severe hydronephrosis iss because of the calculus, obstructing calculus or cancer, whatever, that's when you need to discuss it with your seniors and probably get I are involved because they might want to consider putting in the frosting me, especially if the patient septic. That's the only thing I can think of out of hours that will get the IR consultants out of bed to go into hospital for a septic hydronephrotic um patient. Um I'm not sure what the last case is. So pr bleeding career localization, I think this was pretty much the same. So again, create gi bleed, do a triple phase study, noncontrast because we want to make sure it's not hyperdense material that we've ingested or whatever. So this is a noncontrast study. So even though this was a noncontrast study, this patient has a fair bit of abdominal fat, which makes life quite easy. So we've got extensive diverticular disease in the sigmoid this distance, sending an approximate sigmoid. So this is normal bowel wall, not thickened, normal, you reach here and then you've got this sort of short segment of thicken bowel if I measured it probably about 34 millimeters. So hopefully everyone can appreciate this is abnormal. Additionally, there is minor fat stranding surrounding it. Um So in this region is either gonna be colitis. If there wasn't any diverticular disease, there'll be colitis or if there was a vertical disease, fat stranding surrounding diverticular disease is acute diverticulitis. Hopefully, that makes sense. Um Yeah. And so there's non contrast and the patient had pr bleeding. So we did an arterial phase because we're very diligent and we're just looking for any evidence of a bleed and hopefully everyone can see that blush there. So that's hemorrhage. How do we know? Let's do the portal venous because it was an active bleed. It will get bigger and yeah, it's getting, it's getting bigger, that's bigger. Um Yeah, so this is not only that particular disease, but it's also got acute bleeding. So again, fast track phone call to our to our I are colleagues. That's just a question. Can you repeat portal venous and arterial phase timings? So basics um noncontrast just scan without contrast, arterial phase is about 25 20 seconds, portal venous face, 70 75 seconds, delayed imaging, 10 to 15 minutes. Um I usually do 15 minutes because depending Hardwell or how much, how busy we are because usually by 10 minutes, the the contrast is still within the renal pelvis is not really gone through the ureters, which is the pain because that's usually the question. Um But yeah, it just depends, but baseline delayed is 10 to 15 minutes. Um Okay. So that's all the cases that I have. I'm going to bring you back to my slides as a sort of round up. Let me check the time we have nine minutes. Okay. Um Sorry, I know this has been a bit of a whirlwind, but based off last times feedback, I'm just trying to incorporate as many cases possible. So this one was the case case to. So corona view, hopefully everyone by now can see the fat stranding in the right that Forsa um you've got a short blind ending tubular structure with surrounding um inflammation. This is appendicitis, there's a hyperdense, appendical if seen at this origin site next to the cecum. Um And this is a close up view of it as well. Um And this is just a diagram showing the different sites of appendicitis most commonly is retro cecal. Um case free was the diverticulitis case. So this is a sagittal view. Um I don't think, can you see my my, I'm not sure you can see my mouth but in the center of the screen or center, lower part the screen there is bowel wall thickening. That's the sigmoid colon. There is a lot of fat stranding that region just look in the region of anterior to the bladder, for example, that's clean pristine fat that's normal by the back, just interior to the sacrum. There's a lot of fat stranding, there's bar wall thickening. So this is gonna be either colitis or diverticulitis. Um And I'm just gonna tell you it was arthritis again, just to spot the difference on the image on the right. This is diverticular disease, but the fact surrounding this area is pristine. Therefore, this is not acute diverticulitis. This is just diverticulosis. Okay. Um Case for was the case of the college societies. This is a different case. This just highlights the um localized perforation a lot better. So what I'm, what I, as I said earlier, you're following the thickened gallbladder wall and there's a large defect that is the site of the perforation. Um Additionally, there is like some free fluid, there's stranding around this gallbladder. I think this patient also had a pericholecystic collection. Um Yeah, and then call cystitis. Next case. Oh yes. So um so these are two different cases but just a very important point between free fluid and the localized collection. So the image, let's start with the image on the right. So we have free fluid. How do I know it's free fluid? Because it's the hands for you hounds view unit for free fluid should be less than 20. Um If it's above 20 then it could be is suggestive of either protein ages fluid which can be happening in cancers. Um or it could be a hemoperitoneum. The density of blood, which I think Cameron already highlighted in his CT head top was that it's typically hard for union of 70 70 or 60 to 70 odd which is density of blood because it's more dense. Um But anyway, so going back the right image shows free fluid um don't be confused by this sort of thin layer of the interior of the abdomen. That's just the free fluid butting the anterior abdominal wall. Um look, look around the fluid, there's no evidence of peripheral rim of enhancement. Whereas the image on the left, you've got this very clear, thick peripheral um room of enhancement. So that is how we know it's a localized collection that's not going to go anywhere. Um It has to be drained. Um That's when we call I are colleagues for favors. Um They usually just put in an ultrasound probe and then drain the, put a drain in acidic drain. Um This patient is quite superficial, there's no overline bow so they could probably enter it quite easily. Um Like for example, through here, this patient clearly has had recent surgery, there's a laparotomy wound. Um But yeah, so that's how we differentiate between a collection and free fluid. I hope that's clear. Um Case five was the small bowel obstruction. I'm just going to show this case. So again, like I said, um the case that we showed earlier was small bowel obstruction with secondary to adhesions because there was the abrupt tapering in the right iliac fossa. The second other most common cause for small bowel obstruction is hernias like strangulated hernias, which you can see on this image here. There's a right inguinal hernia which is very abruptly narrow. Um And remember, so you've got multiple dilated fluid field, small bowel loops, which to be honest, the thickening of the bowel walls is quite concerning for vascular compromise. Um If you look at the other cases, the um bowel wall wasn't so thin and it looks very friable. So this, this suggests that the vascular there is vascular compromise and there's very high risk of perforation because the walls are more friable. And again, you've got this fat stranding surrounding this incarcerated inguinal hernia. Um just going back to this image. So this was a diagram just to highlight the importance of mentioning. Um if the ileocecal valve is competent or incompetent, why is this relevant? So on the first image on the left, we've got basically there's an obstruction mass, whatever in the mid or distal transverse colon. So this still descending colon is normal. But because of this obstructive mask, you've got the allocation of the proximal transfers, the ascending and the cecum. So this patient has a competent ileocecal valve, which means that um all your ingested food material, whatever through the small bowel is going to keep going through the valve into the colon. But because you already have an obstruction in the front, it's just gonna get bigger, your colon just gonna get bigger, which means it's at risk of perforation, which is bad. So this is like a time um an urgent thing that needs to be operated on. Whereas if they had incompetent ileocecal valve, as you can see the valve works both ways. So even though there is an obstruction at the front, um and there's some distention of the colon because it can go back into the small bowel. It's not as time urgent for an operation. Um I hope that makes sense. Um So moving on K six was, oh, I don't think we highlighted this one. Um So I don't know, X rays nowadays, we've probably doesn't get as much attention as close to CT. However, there's still a lot to learn from domino X rays. So hopefully everyone can appreciate. So we've got, so this is a front uh abdominal X ray. We've got some bowel overlapping bowel loops here in the, in the right force a somewhere here. Um However, you can see the line, the normal hostile ation. So this tells me that it's probably colon. Um And then we reach this bit of bow, you get, you've got like absence of the normal bowel folds. Um So this is a classical appearance of lead piping in the 25 year old abdominal pain, diarrhea and vomiting. You got, your first guest is going to have to be inflammatory bowel disease, specifically um authority of colitis in this region where you lose the normal colonic bowel folds, you get thickening of the mucosa and fun printing. Um If you want just go on good radio pedia, you can find some very nice cases of fun printing. Um So the same patient has CT and with, with uh ulcerative colitis, what is is, is the name is inflammation of the bow of the colon essentially. So how do we know there's inflammation of the colon, you get thickened bowel walls. Um If there is absence of fat stranding, that just means that this is a chronic finding, um which is the case with ulcerative colitis unless there's an acute flare up. So this patient has got thick walls but the fat and there's no fat stranding surrounding it, which means this is chronic colitis and extends all the way to the sigmoid. This is a view of it and this is another surge interview of different patient but extends the sigma rectosigmoid colons are affected and classically, you know, sparing the terminal island is the ulcerative colitis until proven otherwise. Whereas if it was crows disease, it typically start with terminal I'll itis which again is just inflammation of the terminal island. Um So this was another case just highlighting um colitis because we're talking about about. So the image on the left is a barium enema is a study that's not really performed very much. Now, unless you, you're in Lester, I think they still do it quite actively there, but they don't do it. How um again, it's a classical appearance of lead piping. Um So we've lost the whole, we lost all the bowel folds and the colon, you know where the house rations there is none. And then you've got a broad stricturing here, which is which you can get with colitis. Long term. Remember we said inflammatory strictures Um And on CT we've got pan colitis. Um um pan colitis just means that the whole colon's affected, every segment of the colon is affected. Typically you get that with infection like um C diff the classical seizes high. Remember it for exams? Um C diff CMV E and um CDC envy and something else which I've forgotten about your company is another, see, basically, um which might be helpful for exam purposes. K seven. Um apologies. I know it's nine o'clock, but hopefully we we've got me a few cases left. Hopefully everyone is still able to hold on. Um K seven was abdominal X ray. Um So straight away, you can see there's multiple, the standard bowel loops can is that pneumoperitoneum, we can't tell. Um And so the dominant ratios, the kidney bean sign again, classically, we're all familiar with it. We've seen it in your pedia medical school exams all the time again. Um Sickle and sigma marvelous. Sigmoid tends to rise from the pelvis and extends the right upper quadrant cecal because it's in the right left for site extends the left upper quadrant and you normally lose the house rations um with sigmoid. So this, this one, yeah, kind of maybe a little bit, but it's a bit tricky. This was basically a sigma it marvelous. Um And there was a CT to prove it and that's exactly what it looks like on the CT and the image on the left just shows the swelling will pull appearance which you normally get. Um case eight k sorry case fine. So case nine was the one of the gi bleeding. Um How do we differentiate between upper and lower gi bleeding? Um which was asked previously was you look at the location in, in relation to the proximity to the ligament of tres. Um Anything above it is is upper gi anything below is low gi self explanatory. Um Also important to highlight that uh with imaging, sometimes we can't capture all forms or bleeding, but that's purely because of the rate of the bleed. So for example, with CT angiography, the patient has has to be bleeding at a rate of more than 0.35 mils per minute, which is very specific. So they're basically has to be hosing. Um if which is more, more with like inflammatory disease, that particular diverticula osis. But malignancy doesn't tend to bleed that quickly. So don't be surprised if you do a trip of a CT and there's no bleeding, but the patient's HB is in his boots. It just means that, you know, you might want to consider other forms of imaging like angiography or nuclear medicine, nuclear medicine. Rarely we do it because, you know, by that point, the patient so unstable, um they probably want to be suitable for new clement's in studies because those takes time. Um oh So last thing I want, I really want to touch on is um bowel ischemia. So I had this unfortunate case on call a few years ago um of an elderly lady confused, you know, nursing home, resident, non specific abdominal pain had a CT. Um So this was an arterial phase study. Hopefully everyone can see the contrast in the iota straight away. You see this abnormality on this single slice. Um So this is gas within the biliary tree. Okay. This is when you see the sign, this is abnormal. This is terrifying. This is bad, bad sign. It's been likened to what a graveyard looks like with the dead trees. And I think that's a very good um very accurate uh comparison because basically when you see the sign, it's more or less bad news. Um It's a sign of bowel ischemia. Um Additionally, hopefully, the more astute ones of you, we have noticed that there is also gas will in the stomach. So obviously you do get gas in the stomach normally like, you know, from from food material, like just normal bowel gas materializing. However, if you ever get gas in the nondependent portions of the bow, be concerned because this patient is lying on her back and she's quiet, she got gas in the posterior wall. That doesn't make sense. Um Because if she's laying on her back, gas will float upwards to the top, right? So this was um no tosis um on the portal venous face just again, highlighting how great portal venous is in comparison to the other studies is that hopefully everyone can appreciate the reduced enhancement on the left hepatic lobe. So, basically this patient, her background was she had a f and basically had thrown off clots and he has gone everywhere. Basically, that's how she infected her left hepatic lobe. That's how she infected her stomach. Um, I think she infected her bowel as well. I can remember a small, large bow. Um, but basically, unfortunately, she, she subsequently, um, um, passed away quite shortly after this study because, you know, by this point, there's very little you can do, to be honest when you've got so much organ that's sort of ischemic. This is a subject of view of the same case again, just highlighting that. Um, I guess within about, uh, sorry, the stomach bowls, patient's lying on the back. So that should never be guess extending all this way here. Okay. So, yeah, that was a sad case. Um, so sorry, this gas within the biliary system, as I said, it, there's a term for it, which is called portal venous gas. How can we differentiate that from New Mobile Eah. So, New Mobile E A is a normal finding. It can be, uh, I mean, it's more commonly associated with normal findings. Typically, you know, the patient is post hepatobiliary intervention, ERCPs. If they've had, you know, colleges have not called vasectomies. If they've had any sort of intervention into the biliary system, you can get gas. And the main difference is that new mobile eah is central, portal, venous gas is peripheral and is, you know, look at the images extending all the way to the edge of the hepatic um lobes where snowmobiler is central, we can even get it in COPD. There's a very extensive list of reasons why you can get memorabilia on radio pedia, which I will not go into but just very important to highlight the difference between portal venous gas and memorabilia. And the other thing about ischemia is that no, with CT, a normal CT can never exclude about schema. So if you have a patient who were crying about schema, you know, raising lactic uh whatever paradigmatic. Um No Nayef forever and they've had a CT and it's fine. Don't be reassured because all we have done is captured a moment in time for that patient right after the scan, she can front of a cloth or whatever. And it takes time for um Bauer schema to show itself. Um So that's why I typically, when I reported, I always say there's no late signs about scheme, which is true because I can't tell early signs about scheme I cannot be seen on CT. So that's the main learning point, do not be reassured by normal scan. In fact, a normal scan is the scariest bit because you don't know why the patient's aren't. Well. So signs for um bowel ischemia like a bowel enhancement as shown by the picture. So this is normal bowel, small bowel, hopefully everyone can appreciate the absence. Um They just reduce enhancement of the bowels here. And these basically uh ischemic bowel, stomach, small bowel. Um So like the previous case hematosis in in personality, which is basically a fancy term for saying gas within the bowel walls can be stomach can be small, bowel can be colon, uh pneumatosis, port Alice, which another fancy term for saying Puerto venous gas. Um I think this patient on here you could see a bit of it. Um But yeah, basically normal CT does not exclude bowel ischemia. Um So we're coming to the end of the presentation. Sorry, I know I've overshot by a few minutes. Um Basically all I want you to take home from, from this presentation is that when you see a CT, now ask yourself, what kind of study is this because, um, you know, is it noncontrast arterial portal venous delay because all this has significance? Um You can't say there's evidence of a bleed on a noncontrast study because that there's no contra you've not given contrast, it doesn't make sense and it helps you to narrow down your differentials. Um Second question is, can you see the normal anatomy if not, why is it because of surgery? Is it because of congenital variants, compare prior imaging, you know, um check the clinic letters, see what's happened with the patient most of the time in the coming confused unwell. So that very poor historian. I appreciate that. Um But, you know, we can look at other signs, you know, um any signs of information on CT, like I said, fat is your friend. If you see fat stranding edema bar wall, thickening free fluid, be concerned if it's one of these two things, you can get a bit of free fluid in women in the pelvis that's physiological. Um But it tends to be like a small volume. You know, if it's like moderate society, certain something is wrong. Um Every time you see a primary pathology, ask yourself, is there any complications? Is there a collection? Is there a perforation? Is the obstruction, is the ischemia? Um And that just takes your um uh report that much further. Um Obviously, I forgot to mention fistulas as well. Any, any time you get inflammation of anything, if there's an adjacent structure, there's a risk that it could create a fischelis track. It's basically that point. Um So in summary, we've gone very quickly through protocols, normal anatomy and acute presentations. This is the last case, I promise this is out of interest. Um We're gonna give you a few seconds to see. This is a Domino X ray of a 25 year old female patient. Um uh Yeah, I don't think it's the only way to see what your choices are, but I'm just going to give it a few seconds. So hopefully the radiology amongst you will be well have noticed that there is basically absence about in the center, center of the abdomen and the lower pelvis for whatever reason, everything. So pushed to one side, 25 year old fertile woman. Hopefully, that's not the wrong term to describe women. Um I'm just gonna zoom in a little bit more and hopefully people have noticed it by now, which is why, you know, don't slack off, I don't know x rays. It can be very useful. Basically, I always check for pregnancy test because this was the foetus. This is the skull here. You've got the spine here, hope you can see my mouse. Um And you've got femur. Yeah. So this was the foetus. So always check pregnancy test. Um These are the resources that I've used. Um Hopefully there's any questions I'll be happy to answer them. Hi, Sandra. I think there's just one question that was mentioned a little bit earlier um regarding collections. So in the early case, a collection doesn't necessarily have um like an enhancing ring around it. So in cases like that, would you base more of your diagnosis in the clinical history and examination or would you sort of follow them up with a CT scan? Um Usually if there are sort of approaching like if they've got lots of free fluid and they're approaching sort of getting infect uh infected collection, presumably, they wouldn't go home, presumably because they were still quite septic and unwell. So I don't, I can't see people discharging them. Um, for those sort of situations, I think a repeat ct is completely justified and reasonable. Especially if they are inflammatory markers are not improving if they are clinically deteriorating or the same despite antibiotic therapy. Because like I said, if they, if you have a localised collection, even if antibiotics, depending how big it is, it doesn't tend to go away. The best thing to do quickly is just to stick a drain and, and get rid of all the person things. Um Yeah, really? Well, I think that was all the questions and I personally just wanted to say a huge thank um on behalf of everyone who's attended and on behalf of asset for giving us your time today and also to um Doctor Cameron Spence for his time as well. I know I personally found it really useful and there's so many different parts of this talk that will help me both in my normal day to day practice and my future training and also exams as well. Um I know we're all busy and I also wanted to thank everybody else in the society for Radiologists and training for making these events happen. Um For everyone who's attended tonight, you will receive a feedback link and on completion of your feedback link, you will then be issued uh certificate. Um But for now I'll bring the session to close and Sandra. Thank you. Again and also big thank you to sue from Medal who is behind the scenes and always making sure that the platform run smoothly. And thank you to Sascha, who's able to join us from Asset as well.