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Hi, everyone. Thanks for everyone that's joined tonight. And this is actually our final session in the final years series will kind of the medicine branch of it anywhere. And we've got doctor Delphine Vase who's going to be going through radiology that's relevant to final year exams and also be really useful when you all become doctors starting in August. And so I'll hand over to Dell. Fine. Thank you so much Olivia. My name is Delphine. Um and I, as Olivia said, I'm a junior doctor currently working in Queens in Romford. Um And today I'm just going to go through some of the radiology to really, really help those out doing finals and also your first couple of years as a foundation doctor can be quite helpful. Um So why am I doing this talk? Firstly, radiology essential to patient care and will be ever more. So as, as you know, over the next couple of decades, as we rely more and more on imaging to sort of make diagnosis. Um and also importantly, it will come up in your exams both in your skis and S pas. Um So what um what is sort of outlined in the Royal College of Radiologists um online specification for undergraduate radiology is, is these are some of the presentations that they want you to be sort of familiar with and have seen. Um There's also some on M S K that haven't included here, but uh there is the website just below that you can go and have a look at the full specification, but these are the some of the common presentations they want you to be familiar with. Um And so in this talk, I'll take you through chest abdomen and neuroimaging. Firstly, just take you through a sort of systematic approach to how to sort of go through these scans when you see them um some common presentations you might see and then a couple of S P A S at the end of each section just to sort of go over um what we've gone through in the section beforehand. So let's start with chest X rays. Um This side might seem a bit daunting at the beginning, but it just really shows you this systematic approach that you should try to adopt every time you're reading an image. For the sake of this presentation, we probably won't go into such detail on every image we see just a matter of time. But just for you to be aware that this is something that should be going through your head when you're seeing an image. Um So firstly, you want to confirm those patient details the day and time of the scan. And very importantly in radiology is any previous imaging they've had um on the system, getting the images up side by side is very helpful just because you want to see any interval change. Um And then you want to assess that image quality and helpful pneumonic care is ripe. Um So, starting with rotation and how we assess rotation is we want to see other medial aspects of the clavicles, Ecuador distant from the spine is processes. Um And then secondly, we wanna assess inspiration and you should be seeing about 5 to 6 anterior ribs, um feel adequate inspiration. Um And then projection often, especially with chest x rays, you assume P A unless told otherwise. And usually there's a little ap in the side if it is anterior posterior and then exposure wise, just make sure you can see the spine is processes behind the heart. Um And then it's up, you know, sort of down to the crux of it all. And what's good practices if you can see any sort of glaring abnormalities. Um If you're trying to present this in a Noski or present this to, you know, a fellow clinician, you want to sort of address the abnormality early and say, you know, what strikes me immediately is a large left side of pneumothorax or something before then going on to systematically reviewing the rest of the chest X ray. Um So, well, first we look at the airway, we're gonna um assess the trachea karina bronchi and then the hilar structures, looking at the lung fields in general, then you're looking at the heart, assessing the diaphragm, then what we say everything else. Um, and this includes the bones, any sort of tubes in situ valves and stuff like that. Um Okay. And this is just brief slide about some useful anatomy to be aware of when it comes to reading chest x rays. And um we often instead of referring to lobes, we like to refer to zones when we're referring to the different sections of the chest X ray. Um This is helpful this slide because sometimes um to determine the location of a disease process, it's helpful to have some idea of what sort of uh occurs at each border. Um And the loss of any of these specific contours is what we call the loss of the silhouette sign and could indicate that there is some pathology going there. Um So with that left heart border, we know that that borders against the lingula of the lung. Um So any sort of loss of contour, there would suggest that there's a disease process occurring in the lingula. Um And then we've got either side of the, the hemi diaphragm. If you lose any, either of those, you know that it's the lower lobes, it's probably affected. Um And then the posterior thorax disease, we lose something called the paratracheal, not sorry. Not para para vertebral line. Um So there's just some useful borders to be aware of. So when you're trying to, you know, locate the disease process, um you can be more specific in where you think it's happening. Um Fine. So if we go case one and if, if you've got any idea what I'm showing here, if you mind just popping it in the chat. Um So does anyone know what's happening here? Anyone has it a guess? Yeah, exactly. Thank you, Marie. So here we're seeing sort of a significant left sided pleural effusion. Um And what we call the meniscus sign here and you see this large pleural effusion, it's quite an obvious one, not always so obvious, but what's happened is, you know, you don't see that right costophrenic angles completely obscured. Um And also the, the right uh sorry, left the left heart border and left costophrenic angles completely obscured um fine. And it's important to be aware that when we see a pleural effusion, we want to ascertain is this a transit date versus an extra day? And the way we do this is to the definition of an X today is based on lights criteria. And this is basically analyzes the protein LDH content of the pleural fluid and it helps us to decide, you know, what is causing this pleural effusion. And this slide just sort of briefly demonstrates the different causes of pleural effusions that we see. Um is there in the transit day, it's going to be anything that increases the hydrostatic pressure or that decreases the oncotic pressure. And it's sometimes helpful to think about what's happening on the level of the vessel. So we know that in transit eights, the fluid has to go across the cell barrier. So we know that large molecules won't make it out into the pleural space. So you'll see a sort of reduce protein content and reduced LV age. Whereas with the exudate your that sell barriers compromised. So these larger molecules are going to make it through into the pleural space. Um and just a quick one on too, you know, causes of um transit dates that includes heart failure, cirrhosis nephrotic syndrome. And then in terms of extra dates were thinking anything causing inflammation, whether that being uh infection. So, pneumonia, tuberculosis or is it, you know, malignancy or connective tissue disease? Okay. So, if we go on to this case, I'll just give you a brief issue. This is just a 50 year old male comes in with shortness of breath. Um There is a known background of lung malignancy. Um um what do we think is going on here? Okay. Not much coming up in the chat. That's all right. Um So again, what we're seeing is a huge left sided poor effusion here to the extent that was seeing shift of this mediastinum um and not a pneumothorax as such, everything shift of the mediastinum and shift of the trachea. Um And what we're seeing here is, is commonly referred to as white out of the lung. Um, and where you see this complete a pacification of one side of the hemothorax. Does anyone know how we sort of, um, we group causes of white out into different things, depending on a specific trait of the expert. Does anyone know how we separate them? Okay. No worries. I'm not sure if there might be a bit of delay. But so when we see white out of the lung, you want, you want. Exactly. Thank you so much. A tricky away or towards the lesion. Exactly. Um This helps us sort of group these different causes of white owl according to what the effect is of the disease on the, on the position of the trachea. And this slide just sort of demonstrates. So you've got some causes that pull the trachea towards the pacified side. This is any cause of lung collapse or pneumonectomy. So removal of the lung or even just melt, you know, the lungs never formed in the first place. And then in terms of central causes, you're looking at consolidation, pulmonary edema, stuff like this. And then lastly, like we saw in the previous slide, anything that pushes the trachea away from the pacification. So this is a pleural effusion or perhaps a hernia or large mass. Okay. So case three, here we see the 30 year old male he presents to the emergency department with inspiratory, chest pain and tenderness on palpation of the chest wall after a road traffic accident. What do we see on this slide? Yeah. Correct. We're seeing a fractured rib. Is there anything else that you can see? Yeah, it's in large. Exactly. A pneumothorax is what I'm getting at. But you're, you're right. It's, um, there's, um, definitely increased lung spaces there. So, what we're seeing here is, um, a pneumothorax, we've got a fracture of the rib overlying a pneumothorax after a road traffic accident. So, yeah, correct, everyone's correct there. Um And just to go into, just to remind everyone of the pleural anatomy. So you've got the visceral pleura overlying the lung parenchymatous. You got your inter pleural space and then against the thoracic wall. You've got your parietal pleura. Um And we split the new majorities into primary and secondary causes um sorry, primary secondary, new majorities. Um A primary pneumothorax is one where there's no underlying lung disease and a secondary one is where there is underlying lung disease, whether that be COPD, asthma. CF These are just some examples and, and it's important to make this distinction really because it will influence your management. So it's important to know when you're seeing someone in a and a with a pneumothorax is this primary is the secondary and I don't want to overwhelm you with this lie, but this just sort of address it outlines the different causes of courses of actions depending on whether we're seeing primary or secondary new majorities and to summarize it all really, is that with secondary new math or it ease. So when you know that the patient's got underlying lung disease, we tend to have a lower threshold to insert a drain or two aspirated. Um, and you know, if they've got no underlying lung disease, you're sort of happier to discharge them. So, anyone who's got a pneumothorax under these two centimeters and then not no symptoms and they've got no underlying lung disease. You can be happy to sort of discharge them. Um But if they've got underlying lung disease or if they're symptomatic or it's a large pneumothorax, then you need to start thinking about either an aspiration or a drain um fine. So, into our next case. So this is a 35 year old male. He presents the hospital after a road traffic accident where he sustained considerable blunt force to the chest. He complains of pleuritic chest pain and shortness of breath. You do conduct an eight e examination on assessment on him in the emergency department. Um When you're setting a find the trachea is deviated to the right, the airway remains patent in terms of be, he's got a fast respirator. He's desaturating to 85% on room air. There's a symmetrical chest expansion and hyper resonance on percussion on that left of that left hemithorax. His BP is dropping to 90 systolic despite ongoing fluid resuscitation, um in terms of de his pupils are equal and reactive to light. His G C S 15 out of 15. And in terms of e there's significant bruising to that left chest wall. Um What do we think is a diagnosis here? Yes. So this is a tension pneumothorax. Thank you, ELISA. So, um what we are seeing here is you see the same signs that you see in the pneumothorax. So, you know, you're not seeing any visible lung markings here in that left hemothorax. Um but you're seeing these additional signs of a contralateral shift of the mediastinum atrichia away from the side of the pneumothorax, you see depression of that left hemidiaphragm here and then ipsilateral increased intercostal spaces. So the ribs on that right hand side, a sort of closer together they would be as normal. Okay. So management of attention pneumothorax is important to realize that this is an emergency. These patient's can be quite unstable. Um and you need to sort of decompress the pneumothorax as soon as possible. So, inserting a needle, we say midclavicular line, second, intercostal space um to sort of prevent further shift of the mediastinum and the hemodynamic compromise. You see and something helpful I think to remember is for attention numerous for ACS, use a 14 gauge needle, you need to, you know, nice big needle here. Um fine. So on to the next case. So we've got here, we've got 45 year old. She's presenting with a productive cough, shortness of breath and fever. What is our chest X ray showing here? Get correct pneumonias. Anything further you'd add on here. Middle zone consolidation, correct. Yeah. Well, so lots of people saying pneumonia, middle zone lobar. Exactly. That's what I wanted. So here, we can see this sort of homogenous pacification in a lobar pattern. Um, in this case, it's affecting the right upper lobe. As you can see the sort of well demarcated horizontal fisher affecting that inferior aspect of the pacification. Um and just something to know in terms of once you treat these patient's with antibiotics, it's important to carry out a chest X ray sort of six weeks down the line to ensure that there's been resolution of the symptoms and it's responded to treatment. And in comparison, we've got another case here which um what do people think this shows correct bilateral pneumonia and like the one before being a lobar pneumonia, what do we think this one is atypical could be? Yeah. So lots of great answers here. So this is listen to operate. Yeah. And it's characterized by these small sort of reticular nodular pacification zin bilateral aspect. Um So yeah, it was just another sort of pattern of pneumonia that we see. Bronchopneumonia. Yes, exactly. Um, bronchopneumonia just sort of refers to, it's just a different pattern of sort of where the information is occurring as opposed to, as opposed to sort of affecting just one specific lobe, it's more widespread, affecting bronchi of different regions of the lung. And so it comes up with this different pattern. And the distribution is often bilateral eight and asymmetric and predominantly affecting the lung bases. Although here there's quite a significant middle zone of pacification. Okay, fine. Moving on case eight. So, does anyone what, what's um people seeing on this slide? Exactly. We're seeing it's quite a localized pattern of a pacification here affecting that right upper lobe. And does anyone know any, any pathogens that can sort of result in this pattern of a pacification? Correct TB. Um So this is something just to, you know, be aware of is that TB predominantly affects the upper lobes. Um So if you see something like this, it should make you think um you know, we need to consider TB here. Um Fine what people seeing in this X ray, we sort of jumped away from infection now. Yeah. Cancer. Exactly. Cannonball mats. Precisely. Yeah. So here we've got Pommery Mets and they've sometimes referred to as Cannonball Mets because you've seen these multiple peripheral rounded nodules. Um lots of different primaries can spread to the lungs. Um Some of the common ones include breast, colorectal renal cancers can cause these cannonball Mets, also bladder and prostate. So quite a few can result in this pattern of, you know, metastatic disease. Fine. What are we seeing in this one? This is a difficult one. I think. Well, personally, for me, can anyone see the abnormality in this chest X ray, correct? We've lost the right cross phrenic angle and the pacification we're seeing here is something called the Hampton Hump. And it's um a peripheral wedge of airspace opacity, as you can see in that right hand side where the lung has infarcted. And this is a sign, I mean, very rarely seen, but it can be a sign of a pulmonary embolism. Um Trest radiography is neither sensitive nor specific for pee. So we often, you know, the chest X ray does have a place in pulmonary embolism because we want to rule out other pathologies causing the patient's symptoms. So in terms of, if you're suspecting A P, um you can do a chest X ray to rule out maybe a pneumothorax or a pneumonia that can be causing a sort of similar symptom profile. But, you know, for diagnosing ps chest X rays have very limited roles, but you can very rarely see this sign called the Hamptons Hump where you see this sort of wedge shaped pacification peripherally um fine. So what we're seeing in this chest X ray, we've got both lateral and um a pa pa X ray here. Exactly, hyper expansion. We've got lung hyperinflation here. So we can see quite a few anterior ribs if we count them 1234567. So anything over six anterior ribs and we say it's hyperinflated, we've got flattened, bilateral hemidiaphragm, a small heart. Um And exactly, it's, it's in keeping with the sort of online diagnosis of COPD. Um And on this lateral radiograph, we can, you know, people sometimes describe this as a barrel chested because that's that lateral radiograph sort of resembles a barrel shape fine. This is, this is just to quickly demonstrate how we measure heart size when it comes to chest x rays. Um we draw a vertical parallel line down the most lateral points of the heart and you measure between it. So you want the biggest diameter of the heart you can see and you draw a line there. And then for the thorax, you measure vertical parallel line down the inner aspect of the widest point of the rib cage. And the cardiothoracic ratio should be anything less than naught 0.5, anything larger than that. Then you're thinking a possible diagnosis of cardiomegaly fine. So case 12, what can we see on this chest X ray? Yeah. Yeah. So there is some articulation. It's a difficult one because often for this particular underlying pathology, chest X ray actually has a limited role in in the sort of diagnosis and management. Yeah, perhaps the mediastinum does look a bit enlarged at the top. But really what this this patient has is bronchiectasis. So you've seen the sort of tram track bilateral opacities. Um but like I said, chest X rays are usually insufficient in both the diagnosis and management of bronchiectasis iss and the sort of gold standard investigation for this disease is a higher resolution CT. So if you're seeing patient's with symptoms, in line with the diagnosis of bronchiectasis, high resolution CT is you're sort of go to when it comes here. But this tram tracker pacification can be seen on the plain film. What are we seeing in this patient here? Correct. Merriam. Thank you. Exactly that we're seeing. It's very what some people had to quite fluffy looking. Um But a sort of more systematic way to define the X ray findings in pulmonary edema sec cardiogenic precisely. Um is you're seeing the sort of backswing appearance where you're seeing this sort of pacification around the highland bilaterally. Um You see the curly be lines, which is the, it's putting more detail here. You can see this septal, it's fluid in the septum in the septal lines of the heart of the chest. Um You see maybe an enlarged heart, um you might see some dilated prominent upper lobe vessels which you can see here and then pleural effusions, an easy way to remember. This is A B C D E. So if you're ever having a Noski examination, and you're thinking that what you're seeing is probably a Dema this is a sort of helpful way to work through the different findings of the chest X rate in these patient's fine. What does this chest X ray show? Yep. So the N G tube is coiled. What would you, what would you think about positioning of this N G tube? Correct. It's not in the stomach. Where is it? Yeah. So it's in the, it's in the right lung, it's in the right main bronchus here, correct. There's also fluid in the horizontal fisher, whether that be secondary to using the N G tube when they shouldn't have, could have been. Um, but what we're seeing here is the N G tube is coiled in that left main bronchus. And in this situation, the N G tube should be removed and re inserted as it's quite dangerous if you're using an N G tube, which is inserted into the pool space, the way a way of sort of uh ensuring that you've got a correctly placed N G tube is that you wanted to descend down the midline down the trachea, dan esophagus, sorry, avoiding the contours of the bronchi. You want it to clearly bicep the carina. So, um to ensure that it hasn't sort of followed one of the paths of the bronchi down. Um And then you want to make sure it's cross the diaphragm um in the midline. Um And it's tip is visible below that left hemi diaphragm. Um So my, the bit I use the most just to make sure that N G tube is bisected the carina because then you can, you know that it hasn't followed down the tricky into one of the bronchi fine So just a quick recap of what we've gone through. So we've seen pleural effusions, pneumothorax, both normal, normal, both non tension and tension, pneumothorax. We've seen low burn, bronchopneumonia, TB, lung, malignancy, lung, metastasis, metastasis, pony embolism, bronch excess CBD and MISS and misplaced N G tube. So now we're just going to do some sbs quickly before we move on to the next section. Um So which finding is present on this image? Okay. For the matter of time, we'll, we'll keep moving. So, yeah, let's see. We've got majority answering this. What we can see here is a meniscus sign um in keeping with a left sided pleural effusion so well done to those who answered it correctly. For the second question, a 20 year old female with a high temperature and cough presents the emergency department. A chest X rays performed which answer best describes the appearance of this chest X ray. Yeah, okay. And in this case here, what we're seeing is a is e a consolidation. Um and that sort of occurring in that left lower zone. Um Some people have said inadequate image due to patient rotation. But if you look at the media aspects of the clavicles here, it is relatively equidistant from those spine is processes. So it's not too poorly rotated, it's not perfect. But as I can see where they're coming from, but it's not, it's still, you know, and you could still interpret the image. It's not sort of obscured completely by rotation and then question three, which statement is correct? I'll just let you read through this yourselves and we can answer that. Oh, okay. So yeah, the majority of you have answered correctly here. Um There are some people have said aid X rays of poor quality and should be repeated. And I agree with this in some respects because the inspiratory effort here is very poor. You can only see 1234 anterior ribs here. So poor inspiratory effort perhaps because because of the patient, so and well, they can't generate a good enough spirits, inspiratory effort. But more importantly here, the nasogastric tube, you can sort of see it um following the path of that right bronchi. Um And so we'd be worried that this currently is sitting within the lung parenchymatous and so the N G tube should be removed. So, in this case, D is correct. Now, on to the next question, which physical examination would you expect to present at the time of taking this X ray? Yes, it once put it in the interest of time. Um The majority of answer correctly this patient has um would have a right side of, of the chest hyper resonant to percussion. Um As you can see sort of complete absence of lung markings here, um which indicate most likely a sort of massive pneumothorax, no tension, no evidence of tension here. Question for the end. This is a good question. I will. Um there are three main things that for differentiating between attention and normal pneumothorax, attention pneumothorax, you, what you'll see is deviation of the trachea and the mediastinal structures away from the side of the pneumothorax. Um So it's really just look at the trachea to see is it deviated away? And then that's when you can sort of define that as tension because you know, there's enough pressure building up within the hemi thorax to be pushing the structures away E I E tension. So that tension, that pressure has to be big enough to be pushing those structures into the other side of the hemi thorax. Exactly Marion. Thank you. And finally, um this is sort of more of a Noski style question. So if you don't mind just popping in the chat, your thoughts about each of the questions, what imaging abnormalities can be seen on this radiograph, correct? Thank you Hamza. So yeah, in this trust X ray was seeing that the that cardiothoracic ratio is increased if you compare the sort of size of the heart to the thought to the um to the thorax. Um And what you can also see is there's an increased upper lobe vascular markings exactly up alot diversion. And also you're seeing these plural septal lines that we were talking about the curly be lines and in terms of what is most likely causing this abnormality. So here we're seeing the most likely a cardiogenic pulmonary edema So cardiac failure because you've got this in enlarged heart size as well. And in terms of the most appropriate imaging follow up technique um in these patient's, they often, especially if it's their initial presentation, we spent respond quite well to diary sis, you will probably want to do a repeat chest X ray to ensure there's been resolution of the pacification. Um And uh yeah, an echo, an echo would be an important thing, especially if this is in, you know, their first presentation. Um But in terms of um following up response to treatment and diary cess, you would probably want to repeat the chest X ray. Um but echo is also very important. Fine. Ok. Well, wonderful. We'll move on quickly. I don't want to keep you guys too long onto abdominal x rays. Um And again, you want to be approaching these plain films with a systematic approach, especially in your examinations just to make sure you're showing your examiner that you're thinking through everything. Um So once more, you confirm the patient details the date and time of the scan and any previous imaging for comparison. Um And then you assess the image quality projection. It's important to know whether or not is this an abdominal films? It supine, is it erect as that could um change the way you interpret the image. Um exposure of these plain films is often quite poor with the over allowing the overlying bow does often obscure them the deeper structures. And then again, you know, jump to if there's any glaring or abnormality, it's good practice to address this early and say, you know, I can see this is obvious, um there's some obvious signs of a sigmoid volvulus here or, you know, whatever the pathology is and then, you know, systematically work through the rest of the scan looking at in the entire bowel and any other organs that can be visualized. You want to make sure to look at the bones, any evidence of fractures or, you know, lytic lesion suggestive of metastases or anything like that and any calcification or, you know, anything that just looks slightly strange, that could be an artifact. Um So just a quick sort of whiz through that a very simple diagram here of the gi anatomy, you know, we start with the stomach onto the duodenum into the ileum jejunum. Um then you get your cecum, ascending colon hepatic flexure, transverse colon down into the descending colon and the sigmoid and into the rectum. Um And this is some important things in terms of distinguishing between that large and small bowel. Um This can be quite difficult sometimes with some helpful points to think about when you're visualizing the plain film is, you know, the small bowel will tend to lie more centrally with the large bowel framing that and going around the edges. But this is not always the case. Um You want to look at the markings across the bow. So with the valve like on a vent, a scene in the small bowel, these tend to traverse the whole width of the bow. Whereas the house dried the, what you see with the in the large bowel will not always completely traversed about and they tend to be thicker. Um Also the presence of feces may be a clue towards telling, you know, this is a large bowel that's being seen. So, um, one more thing would be that there's 369 rule. Um, and this basically just tells us the normal diameter of the bowel at different points along its course. So small bowel should be no greater than three centimeters large bowel, no greater than six and seek them no greater than nine. So anyone know what we're looking at here? Yeah. So Hamza, you say dilated small bowel, why is it that, you know, this is small bowel, not large bowel? Exactly. You can see these valvular convent a and they are travertine the entire width of the bow. Um And as we know from our 369 ruled this, um, bowel, the small bowel is definitely over three centimeters. Um And so we're seeing what we're seeing here is a small bowel obstruction. What are we seeing in this slide? Exactly. So here we see signs there are some areas on this, on the scan where you can see in large small bowel, but this is a large bowel obstruction. Um, we're seeing are large bowel loops with the house dry, which are not completely traversing the bow. Um, and it's sort of framing the periphery. So it's another indication that you're in the large bowel here. Um, in this case, the point of obstruction was the distal descending colon. So you're going to see in large, large bowel at the, a small bowel at the same time because your, you know, your, your further distal down the, um, the so obstruction, the large bowel also can result in a small bowel um, enlargement as well. Okay. And this is just a quick one to um run through are the common causes of small and large bowel obstruction. So, um, the most common cause of small bowel obstruction would be in adhesions. Um And the most common cause of our large bowel obstruction is malignancy. So, what we're seeing in this slide here, does anyone know? Yes, Glen. So, thank you very much pneumoperitoneum. It's exactly what we're seeing. So this is an erect abdominal X ray revealing a chris enteric gas under the right diaphragm. And this is indicative we've got, you know, air pneumoperitoneum, air in the peritoneum is an indicative of a bowel perforation. Um, and this is quite worrying sign. The patient's often quite clinically often unstable. Um, so this is something important to know if you're seeing this sign of air under the diaphragm, you need to think about perforation. And, um, you should you know, be escalating this quite quickly to a senior. This is just, um, something else which will be seen in, in bowel perforation. You might see something called reglas sign and rigorous sign. Also known as a double wall sign is a sign of New and peritoneum, um, where you see gas outlining both sides of the bowel wall. So you're, you know, you're seeing gas both in the lumen of the bowel, but also gas within the peritoneal cavity. You only tend to see this sign if there's large amounts of gas in the peritoneum and usually around over 1000 mills of gas. Um, so obviously, often quite severe disease before you're seeing this sign. What am I showing in this slide? So, we've got one for Seiko Volvulus. It's not sequel. In fact, it's a Volvulus correct of which part of the bowel sigmoid. Exactly. So this is a sigmoid volvulus. Um, you're seeing a sort of large dilated loop of the colon here. Um, sometimes this is referred to as the coffee bean sign due to its resemblance to a coffee bean. Um, it's a cause of large bowel obstruction and it occurs when you, the sigmoid colon twists on. It's me century the sigmoid mesocolon. Um, and in comparison to this, what am I showing in this slide? So toxic megacolon. It's, um, it's not just that, I mean, it might very well be that the, you know, it meets the criteria of a toxic megacolon. But more importantly, the main pathology going on here is another volvulus and I sort of showed this just to compare with the previous one. It's volvulus of a different part of the bowel. So this is this is an example of a sequel Volvulus. So here side before this is our sigmoid volvulus, the coffee bean sign and this is a sequel Volvulus. Um and it usually rises in the right lower quadrant, although that's quite hard to visualize here and extends towards the epigastrium. Um And what is, and what's important is the distal colon is usually collapse and the small bowel is distended just because of where the cecum is. Um And so just quickly outlining some differences to be aware of when trying to differentiate between a sigmoid and a sickle volvulus. So firstly, the location, um although depending on what, you know, how far along on the disease you are, the location might not be that helpful. Um So in the cecum, it rise in the right lower quadrant extend towards the epigastrium. The colonic house, your pattern is often maintained and the distal colon is usually collapsed. Um And you tend to only see one air fluid level, should it be the cecum in the sigmoid? However, you are arising in the pelvis or the left lower quadrant and extending towards the right upper quadrant, um you're likely to not see any house tre when it comes to the sigmoid. Um And it causes obstruction of the distal large bowel. Therefore, you're gonna see a dilated, ascending, transverse and descending colon. And um you might see more than one air fluid level. So this is just sort of a helpful slide in terms of differentiating between the two. It's often quite difficult thing to do. Um Fine. What am I showing in this slide, correct? Thank you, Marie. This is um showing extensive thumb printing along the distal transverse colon. Um and thumb printing is a sign indicative of a mucosal Dhiman inflammation. And this often seen in colitis of any inflammation of the bow. What does this slide show lead pipe sign? Exactly. And this is um are toxic megacolon. Um And you can see here the colon is significantly dilated over six centimeters and there's loss of that House Trey Shin that we usually see. Um and like you said, it's sometimes referred to as a lead pipe colon because of its resemblance to sort of a straight um thick lead pipe. Um toxic megacolon is acute complication that can be seen in both types of IBD inflammatory bowel disease, but can also be seen in infectious colitis in particular. See death, clostridium difficile can cause this. Um and what happens if you got, it's a sort of indicative of a fulminant colitis in which you've lost a neurogenic tone of the colon leading to sort of a severe debilitation. And the problem here is there's a risk of perforation So whenever you're seeing this, you also want to have a look for any signs of pneumoperitoneum as we saw earlier in the slides to address any, um, you know, any signs that the bowel has already perforated so quickly on to the SBA so 75 year old male meeting with severe abdominal pain, chest X ray on admission has shown on the left. What is shown on this chest X ray? Yeah. So, um here we're seeing free air under the diaphragm which is indicative that we've got in the peritoneum. And this might be secondary to a perforated bow question to a patient with a history of ulcerative colitis. What radiological finding is shown here? Yeah, sorry. I'm going quickly now just in the interest of time. So this is another example of thumb printing which is just indicative of inflammation of the bowel and it can be seen in you see, question three, what abnormality you've seen in this abdominal film? Yeah. So this is another example of our lead pipe colon are toxic megacolon as you just went through in a couple of slides beforehand. Question for what abnormalities seen on this abdominal radiograph. Please let one of the following diagnoses, pneumoperitoneum, toxic megacolon, paralytic ileus, small bowel dilatation or large bowel dilatations. Yeah. So this is um another example of a large bow dilatations in um the most likely cause of this abnormality. If anyone wants to just pop on the chap. What if they remember what the most, the most common cause of a large bowel dilatation is large bowel obstruction, sorry, cancer. Exactly. Cancer. And is there any evidence of perforation here? So, Reglas sign, I don't think we're seeing Reglas sign here. There's no evidence that there's any air outside of the bowel. So, you know, you're seeing, you're seeing airway thin the lumen, but you, I think it'll be difficult to argue that you're seeing a within the peritoneum. So no, and there's no air under the diaphragm obviously here, although we can't really visualize the diaphragm um completely, but there's no rigorous sign as such and there's no convincing evidence, there's any air in the peritoneum. So I would say no, there's no evidence of perforation, but there is evidence of large bowel obstruction, fine. And if we quick quickly blitz on to um our C T S, I don't want to keep you guys too long. So I will go as quickly as I can. Um So CT pays a pivotal role in the diagnosis of acute stroke and we really rely on it to rule out any hemorrhage. And this is very important because our management of an ischemic versus a hemorrhagic stroke are quite different. And um the sort of um the there's, it's very time critical um to start any um antico anti platelets or any thrombolysis in Aske emmick stroke. And obviously, this is a disaster if you start, if you stumble is someone or if you start anti platelets in someone who's had a hemorrhagic stroke. This can be quite devastating. So it's very important early on when you see someone with neurological signs that might indicate that having a stroke is to differentiate. Is this an ischemic or is this hemorrhagic? And this is where our ct head comes into play. What does this gown show? So we've got one for subdural, not quite epidural, correct. This is an extradural hematoma. Um And we know this because it's a biconvex sharply dedicated hyperdensity. Um And it doesn't cross the suture lines and is continuous with the outer periosteal layer. Um And in depending on the size of these bleeds, you can sometimes get a sort of midline shift which we can see here um where the sort of the set you can see the central structures have been pushed away from the lesion. Um This is just a quick slide to demonstrate um sort of the cause the majority of these um hemotomas they occur in the temporal region because this is where skull fractures cause rupture of the middle meningeal artery. Um And in terms of clinical presentation for these patient's, there's often this lucid interval in between episodes of loss of consciousness. So if you're seeing a patient who says, you know, I lost consciousness as soon as I got hit on the head, um But then now I felt normal and then they lose consciousness again, you should be quite suspicious of an extradural lesion. Um And then in terms of examination, you might see a fixed dilated pupils and this is due to the uncle herniation, um which causes a third crane, third cranial nerve compression. And in terms of management here, you know, it's quite time critical, definitive management is neurosurgical intervention. And this um it just shows why you get extra drills in the region that you do is because there's this region of the skull called the terrian, which is where the four skull bones, meat and it's the weakest part of the skull and it's so it's most vulnerable to fractures. So any trauma to this region can fracture the skull and result in rupture of the underlying middlemen and Jill causing an extradural bleed. Um Something to be aware of what is shown in this slide, correct. Um So this is a subdural hematoma. You can see this crescent shaped hyperdensity um which is sort of spread diffusely over the affected hemisphere. Um With subdurals, you get bleeding under the dural layer and this tends to occurred you two pairs in the bridging veins that crossed subdural space. You tend to see these in older alcoholic patient's um and some and those who are on anticoag um in these patient's clinically, you might see a sort of fluctuating consciousness and you slower onset of symptoms when compared to your extradural is again, the definitive management here is neurosurgical. Um So now in the interest of time, I'll probably stop asking questions and just um with through it, this is an example of a subarachnoid hemorrhage. You can see hypodensities um filling the blood. You've got blood in the basil systems and the Sylvian fissure is. And in severe cases, the blood may also infiltrate the ventricles. But in this circumstance, you're just seeing it in the former too. Um, lumber puncture is so sometimes in 7% of cases, CTS will be falsely negative for subarachnoid hemorrhages. And um if you're still suspecting this patient has a subarachnoid hemorrhage, but the CT is negative. It's important to perform a lumbar puncture. It's important to note that these have to be performed at least 12 hours following the onset of symptoms to allow xanthochromia to develop. Um And it's important, the Xanthochromia measurement allows you to distinguish between just a traumatic plural tap, which is another way that blood might get into the CSF sample. So it helps you sort of know that you're not getting another false positive. Um Some arachnoid hemorrhage is your bleeding under, under the subarachnoid layer. The causes of our either traumatic or non traumatic, most commonly the most common cause of traumatic. Um But your nontraumatic causes you want to think about are ruptured aneurisms N E A V malformations. Another uh type of aneurysm, mycotic, aneurysm or pituitary apoplexy risk factors for these hypertension smoking. Polycystic kidney disease is one of those um correlates. Um um And then clinically, you see this sort of classical thunderclap headache with severe sudden onset occipital headache, occipital headache, sorry. And treatment here is more directed at the cause of the bleed. Um What's shown here is a different type of strokes are a scheme X stroke. And here, um you can see lots of great white matter differentiation with diffuse hype attenuation involving that right parietal lobe indicating there's been a scheme X stroke in this region. Um This is just an example of a cerebral abscess. Um You're seeing the sort of outer hyperdensity with this inner hypodensity. Um And this is just some an a differential to be aware of when it comes to seeing these um hypodense lesions with the thin enhancing rims in the brain. This is an example of a primary brain tumor glioblastoma, important differential for the abscess that we saw previously one way of differentiating the glioblastoma versus that abscess. As you see these irregular thick margins and you might see marked mass effect where you're seeing displacement of the central structures away from the legion. This is a slide just showing um an example of hydrocephalus um where you're getting an abnormal accumulation of CSF within the ventricles, um causing ventricular megaly. You can see these quite enlarged ventricles here so quickly, we just um with his SPAC is our our last ones. Um a 75 and 85 year old man complaining of severe headaches and lethargy over the past three weeks. His past medical history includes atrial fibrillation for which he is warfarin eyes for a CT with contrast to perform. What is the most likely diagnosis here? Yeah, correct. We're seeing this um um subdural hematoma here on the right. Um You can see also a burr hole on the left um which is a neuro surgical intervention for the treatment of subdurals. Um It's this crescent shape, subdural hematoma there. Uh number to a 30 year old man who has been assaulted is brought into the emergency department. His G C S is five out of 15 arrival and he is immediately intubated and transferred for a CT head with contrast, which blood vessel is most likely to have a ruptured in this case. Yeah. So the majority of getting it here, the middle meningeal artery. And this is because as we said before, um we've got that terrian of the skull, which is the weakest part of our skull where all the skull bones meet. Um And this this area is most liable to fracture and can tear apart the middle meningeal which runs beneath the terrian fine. Um question 65 year old female. The background of polycystic kidney disease presents with a severe acute onset headache or examination suggested to the back of the head when describing the location of the pain and exhibits photophobia and neck stiffness. Ct head is done and shown on the left. What is the most likely diagnosis in answer to you, Erin. Is it normal to do the bare hole on the opposite side of the subdural hematoma? This is a great question. Um It's actually one, I'm not entirely sure of the specifics of the neurosurgical intervention here. It may well be that they had a subdural on that other side and that's why the whole was on that side. I'm not sure if it's common practice to go on the same side or the other side to relieve the pressure. But a good question and uh something I will definitely look into. Um But in terms of that question, correct, we've got majority answering some arachnoid hematoma. You're seeing that classic sign of that thunderclap headache, sudden onset occipital headache and signs of meninges. Um So I put meningitis as a potential answer there just as a differential to throw you off because sometimes these patient's are thought, you know, you think they've got meningitis when in fact, you do get the signs of meningism in a subarachnoid hemorrhage where you get that next stiffness and photophobia. So, an important differential to have in mind when you see these patient's post contrast ct brain in a patient with known colon cancer. What is the most likely diagnosis here? Yes. So everyone here getting this right. This is most likely with the background of known colon cancer, metastatic brain disease, you're unlikely to get, you know, two primaries occurring different locations at the same time. So here it's most likely metastases. Thank you so much. I'm so sorry for overrunning. Thank you all so much for listening and answering all those questions. Um Your feedback be much appreciated if you could follow this um barcode for me. Thank you all for listening. Thanks, Delphine. Thanks, Delphine. That was really useful. Um Really good that people are engaging throughout as well. If you can either scan the QR code or have put a link in for the feedback, it'd be really useful for Delphine portfolio and you'll all get a certificate of attendance as well, which you can put on your portfolio's and it'll just help us plan future sessions. But I think that was definitely useful for exams, which is definitely useful for practice as well. Um To thank you for that. Has anyone got any burning questions before we um exit out of the session? It doesn't seem so. Thanks, Delve E L V. Delphine. Exit this now. Thank you. Thank you, everyone. Bye bye.