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Slides and they're all good. Yeah, cool. Ok, fantastic. So, thanks very much for having me. My name's Adam. I'm a radiology registrar working at ST George's. Um and I've been asked today to get a lecture on abdominal x rays. So I'd like to start by apologizing because I'm not really gonna talk much about the approach the abdominal x rays. Um But what I'm gonna do is uh talk you through some of the conditions that you might be expected to know about from abdominal x rays and we'll show some of the common X ray patterns. Um Just to give you a bit of perspective. I graduated in 2017 from U C L. At least I run a finals course called Fun Facts for Finals, which is where this lecture is from. So this is like a 2.5 hour lecture on everything that I think you need to know for finals for surgery. Um But the first bit of it is all about the conditions that you might see on an Abdel film. So the reason I agreed to do this lecture, even though I'm not teaching you about how to read and Abdul X ray is because I think that it's better for you guys to know just what the abnormalities on. And I'm gonna explain how to recognize them really quickly. And I think that's about strategizing for finals. So I'm going to assume that you're all um in a variety of clinical years. I don't know if there's any pre clinical people like pre clinical medical students amongst you. But assuming that you're all in yet that, you know, the 3rd, 4th or fifth clinical years, that would mean that you're probably at some point either preparing for stuff that you need to know for finals now or at some point in the future. So I hope this will be useful. Um And as you can see this lecture has SBS and content on every surgical specialty, but we're going to be focusing on, on skis, upper gastrointestinal diseases HPB and then they put on lower gi too. Um So I just wanted to start by giving you all a bit of an insight into what it's like being a doctor because there's a big mismatch between what you learn at med school, what you see at med school and then the experience you actually have as a doctor. Um So I graduated in 2017, my first job was as an orthopedic uh F one. And it was very strange to me like the responsibilities and tasks that I had the kind of knowledge that I needed, had nothing to do with med school. A lot of it was like kind of practical and knowing how to run the board, etcetera. And one of the things that I learned when I was in F one was how to do a ward round. So when I was at U C L like part of the skis was setting up stations that would be realistic that reflect what your life is like as an F one which I think is quite clever, not sure how I feel about it, but I think generally is sensible. Um So for example, I had uh a Noski station in like my first clinical year where we had an ABDO X ray and rather than being asked to look at that under X ray and present its findings, I was asked to write in the notes and entry which is quite reflective of what your life might be like. As an F one, you might be asked to look at the imaging and then put an entry in the notes. So it was a little bit more reflective and I can put a plan in the notes again which is very reasonable and very reflective of real life clinical practice. So the surgical ward run goes something like this. If you were preparing the patient's notes, you might start off by writing down the observations. So that's going to be things like temperature, heart rate, BP, respiratory rate, um urine output, which is very important in in surgery. And an important part of the surgical assessment is if the patient is eating or drinking might sound really basic. But we need to know if the patient is eating or drinking. Are they able to keep fluids down? Um, then we look at the urine output and the fluid balance chart that's pretty important in patients who are like quite unwell. And then B O is bowels open. So we want to see is the patient opening their bowels. And there's also something called the Bristol stool chart. So we make a decision on whether or not the patient, for example, is having diarrhea or if they're constipated, those are really, really important things that need to be actions and we'll then look at their calves and examine to check that the calves are soft and nontender. And the reason for that is because if patient's have had surgery and they're like immobile, they're not moving around, they're at risk of developing a clot in their legs and that's called deep vein thrombosis. So we need to check that their calves are soft, nontender. And if their calves are tender or red or big, then we might want to do some tests to make sure they have a DVT. And that basically is going to be a D dimer. And an ultrasound Doppler of the legs is that comes up in your sbs. And then because I was an author, we used to do this thing, which was envy plus, which means neurovascularly intact. And the reason for that is because if a patient has uh an orthopedic injury like a fracture of the bone or a dislocation, they can have injury of the arteries, arteries and nerves that are surrounding the joint or the injury. And so the distal vasculature and neurology might be affected. So it's very important to check that document it. I've got my first SBA for you and away you go, I am in full screen mode. So I can't really see the answer to um the pole, but I think it's good for you guys to vote and then I'll just go through the answer in like 20 to 30 seconds. Again, you need to be very cognizant of the game of uni which is to smash your exams, right? So I think when I was at uni, I calculated it and I think we got like 72 seconds for each S P A and I'm going to assume that you guys still use S P S which are single best answer questions, which is what this is. Um Yeah. So you had like a minute, maybe a bit less actually. But basically when you divide the number of questions by the amount of time given, you got like a minute per question to read through the question and decide on what the best answer is, whatever. So we have a 27 year old lady now already you should be thinking something's and stuff about the fact that she's a young lady, which is that she can be pregnant. That is the first thing you need to be thinking. And that's why this is the first SBA because this is something you seem to get out the way it needs to be a very, very important. First step. She presents to the emergency department with central abdominal pain, vomiting and anorexia. That is a very, very classical history for early appendicitis, which is what this question is alluding to in appendicitis. Patient's get central abdominal pain, migrates to the right iliac fossa. On examination, the pain is now in the right iliac fossa world classic. So that's the right lower quadrant were saying that when we examine the patient, they have pain there. So the most likely diagnosis is uh appendicitis and the question doesn't ask you what the most likely diagnosis is. It asks you what the next best step is. And the answer is a urine beta HCG. The learning point of this question is the S B A paints an image that this patient has appendicitis. But because she is a female of childbearing age, the absolute first thing you must do is rule out pregnancy. If the patient is pregnant, that completely changes the clinical history. If the patient is pregnant, it can't have imaging of the abdomen. If a patient is pregnant, they might have a ruptured ectopic pregnancy, it just completely changes the differential diagnosis. So just get in your head if you're ever in an S B A. One of the very first earliest things you must be considering is whether or not the patient should have um pregnancy testing dumps. Next question. That's right. Okay. So this is 27 year old lady. So again, we already talked about the possibility of um of pregnancy being something we need to rule out just pain in the right lower abdomen and feels dizzy. The BP is 83/41 which is very low and the heart rate is 100 and 25 which is high. What's the most likely diagnosis? So, this is a patient. This is the reason why we need to do a pregnancy test. And the reason for that is any a female of childbearing age who has abdominal pain should be considered to be pregnant until ruled out until proven otherwise. And the reason for that is if you have a young woman who's pregnant and she has abdominal pain, there is a medical emergency that she could have, which is ectopic pregnancy, which is when she's pregnant. But the pregnancy is implanted outside of the uterus. And then because it's not in like the right place, the pregnancy or the just the gestational sac ruptures and then the woman can sanguine it blood into her peritoneum. So a topic, pregnancy is the most likely diagnosis here. This lady is basically probably bleeding right into her abdomen and therefore, is hypertensive and tachycardic and that is called shock. So this woman has hemorrhagic shock and the most likely diagnosis is ectopic pregnancy that must be ruled out first. This is going to be very easy. You would do a urinary pregnancy test and then if it was positive, you would take the patient straight to theater. You want to do any further imaging, you'd go open up the abdomen laparoscopically and explore it. So that's what we've just said, which is the ectopic pregnancy must be considered and ruled out using a pregnancy test and a urinary beta HCG, which is the same thing in every woman, a child bearing age with shock or with ABDO pain or with syncope or bleeding, then this condition must be considered. Also this condition you get shoulder tip pain, which is referred pain because of I think um irritation of the peritoneal lining cool. So I would say those were just a prelude to like abdo x rays and surgery. General, any woman with abdo pain, you need to do a pregnancy test. So abdominal surgery split up into upper and lower gastrointestinal conditions and then hepatobiliary conditions, which we'll talk through all of them and finally were on some ABDO films. Now, um I would recommend that you Google the radiologist page. Um He's kind of big on Twitter and he publishes these infographics which teach you about a systematic approach to the Abdo film. So as I was alluding to earlier, I don't really think that there's much benefit to you guys of knowing like, you know, like with the chest X ray, there's a B C D E, I don't think there's any benefit of knowing the same thing for anything. I don't think there's any benefit of knowing that for E C G S. I don't think there's any benefit of knowing the systematic much the chest x rays or ABDO X rays because your job is not to interpret imaging, that's the job of radiologist. So, um to be fat, I'm at the radiologist like Radiology Society. So maybe I could have uh taught you all about that. But I know that it's coming up in a future lecture. I think for your exams, most of this is about pattern recognition. You should be able to look at these two images and straightaway know that these are bowel obstruction without any other information because that is the level that you'll be tested out of finals. Just pattern recognition. If you're presented with an Abdul film of finals, there's like six conditions you need to know about and we're going to go through every single one of them right now. So as I said, you should be able to look at this straightaway and know that these are abdominal films of bowel obstruction, bowel obstruction, to simplify it comes in two varieties, small bowel obstruction and large bowel obstruction. And on the left here. I hope you can see my cursor as well. Um You can see that this is small bowel obstruction. And the reason for that is because you have dilated loops of bowel, which are in the center of the abdomen. And you can see that there are these lines that go across. These are called valvular icon Aventis and they, they traverse the entirety of the bowel lumen. So this is exactly what small bowel obstruction looks like. And on the right, you have large bowel obstruction and these are peripherally placed, dilated loops about. So you can see the outside, on the outside of the abdomen, you can see that they have house tre house tre these indentations and you can see that they do not go all the way across. So that is the main, those are the main differences between SBO and LBO and obviously just to review the anatomy in a very basic sense, you have your mouth and then you eat your food and swallow it and it goes into your esophagus. And then your esophagus goes to your stomach transiting via the G O J, the gastroesophageal junction and then the stomach goes into the duodenum, which is the first part of the small bowel. Then you have duodenum, Jejunum ileum and there's all small bowel and then you get into large bowel and the ileum goes into the cecum, which is in the right iliac fossa here. So that's where the cecum is, and that transition point is called the ileocecal valve. So there's a valve at the transition point between small bowel and large bowel. And then I hope you remember again, just very basic anatomy. I hope I'm not, uh I hope this isn't too basic, but it's worth recapping the basic stuff and knowing that incredibly well, large bowel is ascending colon, transverse colon, descending colon and then the sigmoid colon right at the end and then it becomes the rectum before it goes to the anus. And that's where feces comes out. So that's just a very basic review of the anatomy. Very basic. And that's the difference between SBO and LBO SBO centrally placed dilated loops about with valvular convent is LBO peripherally placed loops of large bell with Telstra. That is a summary table of everything. I've just said. Important things to remember are that these patient's generally present with vomiting, they can't eat and drink and they will have constipation by that. We mean they're not passing flatus, so they're not passing wind and they're also not passing feces, they might have not gone to the toilet to open their bowels for some days. So, patient that's not eating and drinking. So nothing's going in and nothing's coming out. And that's because there is an obstruction in the gastrointestinal tract somewhere. So on the left, we have small bowel obstruction, which is what I said earlier. Centrally placed, dilated loops about with traversing valve really con Aventis now classically in the history and this is just like SBA stuff, but these patient's will present more with vomiting. You can imagine if you have a troop a tube going from your mouth to your bum. And the job of that tube is to process food. If you was an obstruction, that's proximal, that quite high up in the tube, then things are going to come out from the top earlier. So that's why patients with small bowel obstruction where the obstruction is more proximal are more likely to develop early vomiting. And the causes of this is really important. This is something that's worth getting into your head because if I was on a ward round with you and I said, what are the causes of small bowel obstruction? You should be able to just real office list. The number one is gonna be adhesions. What are adhesions? Adhesions are like fibrotic scar tissue that develops in your abdomen after surgery. So if you want to see a patient and they weren't eating and drinking and they had constipation and the patient said to you, oh, I have a surgical history. I've had surgery a few times in the past and that included laparotomy and open abdominal surgery, etcetera. Then you need to think in your head. Oh, gosh, this patient might have adhesions in their abdomen and that's the cause for their small bowel obstruction and the second causes a hernia. So any hernia of bowel anywhere where it shouldn't be in the abdomen is going, it's also a top cause of small bowel obstruction and the large bowel obstruction, as we said, the loop Zavala peripherally placed, they're dilated with house tre visible and this is going to present more with later vomiting. So again, we've got a more distal obstruction and therefore, the vomiting is not going to be so present in the picture. And another thing that can happen with large bowel obstruction is called feculent vomiting, which I have seen in A and E because it's pretty horrible, which is that the large bowel where you basically start to make feces is now obstructed. And if that patient's obstruction is severe, then that large, that, that feculent matter can back up all the way up the gastrointestinal tract and they can start to vomit it. So they're basically vomiting poo. Um, which of course is pretty severe and very unpleasant for patient's. So that might present more in large bowel obstruction. And these are the top causes of large bowel obstruction. It's more likely to be like a mass. So CRC is colorectal cancer. Diverticulitis is a condition we'll talk about later where you get out pouching of pockets, a bell, um, in the kind of left iliac fossa where the sigmoid colon exists, uh, seek a more sigmoid volvulus, which we'll talk about in a second because that has very specific abdominal from signs and fecal impaction, which you can see in elderly patient's, I'm just gonna check. Um, is there anything in the chat? Um, so I can see you guys got some polls and that's great. I hope you guys can see the results to the polls and I hope that so far it's all good. Um So let me go back to my presentation. I hope you can still see, not just a mute and let me know. Okay. So we were talking about bowel obstruction and you can see, I'm changing my slides down just to check. So, uh there is something called, which we'll talk about an abdominal films again, relevant abdominal films, which is called the 369 rule. And what that states is that if we go back to this Abdo film that the lot to, to determine if there is debilitation, then the small bowel should not be larger than three centimeters in diameter, which is this, the which it probably is here. The large bowel should not be larger than six centimeters in diameter, which it is here. And the cecum which is in the right iliac fossa should not be bigger than nine. So 369. And if you have bowel that's larger than any of those dimensions, then you should be thinking about bowel obstruction. So the management of bowel obstruction is this actually is a bit of an oversimplification, but I think it's appropriate for finals, which is the management whenever you're asked about the management of anything. You're gonna be answering with a structure ideally because they really love structure and clinical medicine. So you're gonna be saying something like the management is gonna be conservative initially and then medical and then surgical so conservative management is called kind of like doing less, so less is more. So you would admit the patient, that's a really important thing to say if you're actually a doctor, which is you need to make a decision. Do I admit this patient or do I send them home? And with these patient's with bowel obstruction, they're normally going to be quite sick. So you admit them and drip and suck is the old school name for IV fluids and a nasal gastric tube. So, what you are doing is you're giving IV fluid because the patient is likely to be dehydrated and you're giving me, you're inserting a nasogastric tube. So a tube through the nose down into the stomach. And the reason you're inserting that is to decompress the stomach. So you're providing away for that obstruction to be decompressed. That's very important. If you don't do that, the patient will possibly, you know, develop worsening bowel obstruction, the feared end result of bowel obstruction, which is what you have under here is perforation. So you can imagine there's an obstruction of this tube. Everything proximal to the obstruction is just going to expand and expand, expand and eventually might pop, which is what perforation is and if a patient developed perforation, then all of the contents of the gas or the lumen of the gastrointestinal tube will flood out into the abdomen and they will develop peritonitis, which is inflammation of the peritoneum. And those patient's are profoundly unwell and they need to go to theater. This is a um summary to talk about the different types of pathology that underlie dilated bowels. So again, I talked to you about 369. You should know now what dilated loops about looked like on an Abdel film. And if you were looking at an Abdul film of dilated bowel loops, you need to be asking yourself questions like is this small or large bowel with the Elocon Aventis or astra? Are the loops central or peripheral? Is it actually mild irritation? Is the 369 wall broken? In which case, there's bowel validation in real life. When you look at an Abdel film, it's very possible that you come across the film with dilated bowel loops and they have a bit of everything going on and there's no clear pattern. But for the level of finals, you will be tested on questions where obviously there is one disease going on, maybe two and it'll be a bit easier for you to pick uh those things apart. So we've talked about bowel obstruction already. But remember the clinical presentation, which is, these are patients who are have abdominal pain, they're not eating and drinking and they have constipation and they will be probably vomiting. So we've talked about small and large valve. Those are very classical. If you see these on an X ray, you're probably quite lucky because it's quite rare to see an X ray. So classically presented with that, there are two other associated conditions which are other um conditions that cause this presentation and dilated bowel loops, but they're not really obstruction. So the first of them is pseudo obstruction, which is where the patient's present like this. But you might do, for example, a ct of the abdomen and find that there's no mechanical cause of the obstruction. They just have dilated bowel loops and that is called Ogilvy syndrome. That is the eponymous name for that condition, which I've got an image of it. I'll show you shortly and then there's another condition called paralytic ileus. This is very, very classical. It's an important condition. And in this condition, these patient's have absent bowel sounds. So, one of the classical findings in a patient, the bowel obstruction is tinkering, bowel sounds. I e you listen, you auscultate the abdomen and it sounds like they have a, uh one of the things they used to say was like, imagine putting a pebble in an empty can and then rattling it around. That's what tinkling bell sounds. Salad and they actually do sound like that. I've heard them. But in paralytic ideas, what we're saying is that this patient normally will be post operative and it's almost like a, like their bowel is in a shock state. So their bowel doesn't parastatals and therefore they have absent, bowel sounds. So, rather than tinkling, they'll be absent. And those are all the kind of bowel obstruction syndromes. This is a patient that I saw when I was doing orthopedics. It's a 60 year old patient who had an intramedullary nail for a proximal femoral fracture. So you can see now how as an F one in orthopedics, this was a patient with a broken bone, but I was well, I wasn't required to interpret this imaging at all. It was just interesting. Um So what you can see on the right hand side is bowel obstruction. You can see huge dilated loops, a bowel. Now, this is what life is like as a doctor. It's not all neat patterns of centrally dilated loops of bowel with Val Valley Convent is no, there's just huge loops of bowel everywhere. It's quite difficult to determine. Probably what you have is large bowel obstruction, which is, you can see these house throw here really nicely demonstrated and probably small bowel with central dilated loops as well. And on the left hand side, you can see their CT and you can see this huge bowel dilatation and this patient had no mechanical cause identified for their bowel obstruction. So remember if the large bowel is dilated, they probably have large bowel obstruction. They have large bowel obstruction, they probably have an obstructing lesion like colorectal cancer or diverticulitis or a mass or fecal impaction. But we found nothing on this patient scan. And therefore the diagnosis was pseudo obstruction or Ogilvy syndrome. Next question. And again, these are all kind of surgery imaging questions. So, forgive me, I'm, I'm straying into uh chest x rays as well a little bit. Okay. So I want you to see this question and in a similar way to when you see a young fertile female to think about you doing a urine dip. You need to look at this question and think the first test is always an erect test. X ray. It's just always always direct. Chest X ray is gonna be the first test that you need to do because it's cheap, it's inexpensive, it's minimally invasive. There's almost no ionizing radiation. It's a very safe first important X ray like first test to do. So let's go through the question. We have a 37 year old man actually have a friend who this happened to. So this is real presents to anne with severe abdominal pain. It was recently discharged from a knee with a sprained ankle, playing football is exactly what happened to my friend. Examination is difficult due to pain and his abdomen is tense but not distended. What does that mean? Another way of saying that is that he has peritoneal take e there is inflammation of the peritoneum to the extent that his abdomen is rigid like a washing board, which of the following is the next best investigation. Uh So all of these are kind of imported tests. So an A B G is probably not going to be very relevant. These don't really happen anymore. A BGS are normally done for patient's with pancreatitis to risk stratify or patient with severe respiratory distress, patient's with pneumonia, probably Angelis, etcetera. Serum porphobilinogen is a funny answer that is alluding to acute intermittent porphyria, which is a very rare, very rare, like genetically predisposed medical cause of abdominal pain. Urine dipstick is really important but not relevant. In this case, it's not gonna be the first thing you'll do because if this patient is parity knittig, it's unlikely to have a urinary tract infection. That's not how urinary tract infection presents. An ultrasound abdomen is a very good idea. But uh erect chest X ray is going to be the first investigation that you're going to do. The reason for that is that basically this patient is basically this patient has been someone's got there Michael, so I can hear myself sorry. Uh Yeah, you're good, thanks. Um This patient has been discharged from Anne with a musculoskeletal injury. And what they've done is taken lots of nonsteroidal anti inflammatory drugs. So like naproxen things over the counter and the thing that my mate actually did was he wasn't medical. So he just basically overdosed on nonsteroidals because he was in a lot of pain. And what ended up happening was that he perforated a duodenum or ulcer. So he obviously was very unwell. And if you have perforated an abdominal viscous or to say that in like late, um, if you have popped a tube of bowel, then air that's in your gastrointestinal tract will enter the abdomen and rise to the top of the abdomen and sit under the diaphragm, which is what this is. And the reason it has to be erected because they have to stand up. So the air rises to the top. So this is an erect chest, X ray, the chest looks fine and you can see that there are these black rims of lucency under the diaphragm is bilaterally. This is a patient who I published recently with a colleague who had a history of alcohol, excess and low mood after losing his job due to COVID. And what you can see is that the patient basically perforated similar story perfectly to the duodenal also, which we'll talk about in due course. And what you can see is air under the diaphragm. So probably what would happen next is that these patient's would then get a ct of the abdomen and pelvis. With contrast, the reason for that is to try and look for the source of perforation and like delineate the extent of the problem. And then the surgeon will probably decide if they can be surgically managed or not. Next question I think this is a pretty good one also just to clarify. I'll be stopping at like 50 past. So, I mean, yeah, I don't know if there'll be any questions, I assume not, but I think it's better to just go through stuff. Maybe if you have questions, you can email me. We'll stop at about 50 past. Okay. So this is quite a quick one and the answer is the keel Aditi sign. So I was hoping that I might trip some of you up and that you'll look at this chest X ray and go oh my God. There's like air under the life rams. This is like this is a perforated abdominal viscous, which is what I just showed you. If you compare that at chest X ray to this, what you will see is that this is not a runner, the diaphragm, this is bowel under the diaphragm, this is stomach on the left hand side. So this is not a riff. It was aired would track all the way under this diaphragm right out to the periphery of the abdomen. On the right hand side, you can actually see this house tre. So this is probably the hepatic fletcher, which is the top of the ascending colon as it sits near the liver. And sometimes what happens is you get into position of that loop, a bell above the liver and under the diaphragm. And that is called the keel Aditi sign. And sometimes you have a rare condition called kill A DT syndrome, which is where they have this and it causes symptoms, but this person is pain well and pain free, highly lymphaden. What? Let's go, just go through the other options. So this is an 83 year old man who fell in, who fell and presented to A and E and he's got a chest X ray. Uh So there's nothing really suggestive in the stem of the SBA this could be anything looking at the film. The chest is basically clear. There's no highly lymphadenopathy because that would basically be bulky whiteness here and here. And then if I asked you, what are the causes of highly lymphatic feet? Again, you need to have like a nice list in your head for finals. The most important causes are gonna be sarcoidosis, tuberculosis, lymphoma. Those are gonna be the top ones perfect and abdominal viscous. So that's like the red herring like that. I want you to trip up on and say, oh, I think it's a perfect abdomen diskus, but it's not. And then rib fractures you normally see here when you're actually tracing the ribs. And I find them quite difficult to see even now as a radiologist. So they're not always easy to spot. So the answer is the keel Aditi sign. Now we're gonna talk about Abdel X rays. So I think that there is a list of rare conditions that you can see on an Abdel film. Okay. So this is not about a systematic approach to Abdul X rays. The question is like if you are in finals and you're flicking through your paper, not even finals, two year, three year, four year, whatever, you're flicking through your paper and Abdullah X ray comes up, you should be able to not think, look at the X ray and just know in five seconds. Oh, they're testing me on SBO Oh, they're testing me on the regular sign. I think if you get an Abdo X ray and this was my approach to med school, which was there's so much medicine you could learn, don't learn all of it. You need to strategize and prioritize. You need to learn the common stuff, the emergencies, the things that are very common in clinical practice and then you learn so you a portion that the majority of your effort and then the rarer stuff like kill Aditi sign, you just need to have heard of maybe once because it's very unlikely to come up. You know, the embryo sign, you need to have heard of less, relatively speaking than the 369 rule or how to manage SBO or what valve really kind of intisar. So I hope that imparts that kind of strategy that I used to have. So you need to look at the film if you get one and just be like, oh, it's coffee bean signed and then you have your answer So these are the three or four conditions. I think you need to know the coffee bean sign is this one which is in the bottom left which lovely looks exactly like a coffee bean. And what you can see is that this is volvulus, which means twisting of bowel on its mesentery like on its attachment to the abdominal wall. If the bowel twists, then it can like dilate. So sigmoid volvulus, remember that the sigmoid colon is the end of the descending colon, which exists in the left iliac fossa. And for that reason, the bowel dilates away and points towards the left iliac force up. So I hope that really is clear. So the the the dilated bowel points towards the site of the problem, which is the left iliac fossa that's called sigmoid volvulus. And it results in this coffee bean sign looks like a coffee bean. Then you have the embryo sign, which is seen here on the bottom left image. And what you can see is that, that like the center of this, it's not been, but the center of it points towards the right iliac fossa, which you'll remember is where we said the cecum is at the junction between small and large valve and the ileocecal valve. So I think this is when the normally the cecum is retroperitoneal, but when it's not, it can then twist on its recent tree and that's called sickle volvulus. And you get this embryo sign which you can see on an ABDO X ray. And then you have the regular sign. This is really important. It's very classic. But we said, remember when we have this appearance, this is called pneumoperitoneum. You know how you have pneumothorax, which is Aaron the pleural space, pneumoperitoneum means air in the peritoneum where it should not be there at all. So another X ray sign of pneumoperitoneum is called the regular sign. And this is where you can see, this is what this top left images meant to be showing. It doesn't show that. Well, I'll show you another one. It's meant to be showing that you can see the entirety of the bowel wall. So when you look here, for example, you can see the inside of the bowel wall and you can see the outside of the bowel wall. And that is called the double bowel wall sign or the regular sign, which is the eponymous name for that. Remember that the best indicator. So this is gonna suggest pneumoperitoneum. This suggests. So what again, this is like proper radiology where Radiology society let's talk radiology. So there is a very important principle in radiology that you can read about called the silhouette sign. And what that states is that in order for me as a radiologist, looking at this picture to determine that there is a difference in two densities, there must be this difference in density, they must be different in density. For me to see the distinction between them. So the reason why I can see both sides of the bowel is because there's bowel which is soft tissue inside the bowel is air because there's pneumoperitoneum outside the bowel is air. So now I can really see clearly the inside of the bell and the outside of the bowel, like the wall is very clearly defined, that is called the silhouette sign. And that is what you see in rigor sign where you have inside the bowel outside the bowels all. And then you can see both sides of the bowel. Remember that the best indicator for pneumoperitoneum is going to be an abduct, an erect chest x rays, we saw showing air under the diaphragm or the regular sign, as we've just said, and you can get a false positive and peculiar DT sign, which we've also talked about. So now I just want to take a bit of time to go through, got about 10 minutes left. Um So I'll just go through a little bit on uh peptic ulcerative disease. We'll just whiz through this and then try and do a little bit of hepatobiliary stuff because there should be some imaging there too. So, uh gastric ulcers. Well, we talked about those because that's a cause of this appearance, which is pneumoperitoneum or an air under the diaphragm. And basically some important things to remember are that gastric ulcers are associated with or caused by excess at this this point in the bottom, excessive alcohol intake, the use of non steroidals, which can cause irritation of the gastric lining. That's called gastritis steroid. That's really important to see that clinically a lot. So patient's that might have rheumatological conditions that are a or patients that are on steroids for any other condition, maybe inflammatory bowel, those steroids can cause gastric irritation h pylori, which is a bug that basically can cause peptic ulcers that we'll talk about. And that's why when you're a junior doctor, you will see that when patient's get prescribed things like naproxen, which is a non steroidal or prednisoLONE, which is a, a, a steroid, we often give them PPE I cover so we'll give them lansoprazole or omeprazole. And the reason for that is to stop or minimize that gastric irritation. Um There are basically two types of ulcers that you need to know about, which are duodenal ulcers and gastric ulcers. As the name suggests the location, duodenal ulcers classically are relieved by eating and gastric ulcers are the opposite. So they are worse when eating. And the reason for that is if you have an ulcer in your stomach, when you eat food, the food goes into your stomach and you get release of acid into the stomach like, you know, hydrochloric acid to digest the food when that accident is the stomach is going to irritate the ulcer. So, classically, gastro, like, do you like gastric ulcers are going to be irritated when you eat food. And do you do a deal, ulcers are relieved by eating food. He looking back to pylori is an infection that's basically associated with peptic ulcerative disease, which is this like umbrella term for these two conditions and associated with most the US and the US. And it's also associated with acute and chronic gastritis, cancers of the, of the stomach and other types of lymphoma. Uh This, I think is a bit much. But basically you can do testing for Helicobacter pylori. I think it is a bit much. But basically, if a patient has these kind of concerning symptoms, like dyspepsia is kind of generally problems with pain and eating. Essentially if patient's have dyspepsia and you are concerned that they might have a G or do you, then you can do the low carb uh Helicobacter pylori testing. I think that's a bit above finals, to be honest. And then there's a treatment of choice regimen which I've copied and pasted this from the nice guidance. And I've summarized my idiot version here, which is what I used to remember. So this is my summary for peptic ulcerative disease. It's a common cause of again, which is an upper gi bleed, which is a medical emergency, which is important in general medicine and gastroenterology. So when you're learning in those two areas, you need to be learning about how to manage an upper gi bleed. And basically, when you learn about upper gi bleeds. They have like petra, it's either a peptic ulcer or it's going to be like esophageal varices, which is patient with alcohol access and stuff. So, peptic ulcer disease, alternative disease is an important cause of upper gi bleed. The investigations for a patient like this might be a full blood count, it might have a raised urea. So the question I'll ask you now is why would a patient like this have a raised urea? And the answer is if they have a perforated abdominal viscous and they have blood going into their gastrointestinal tract, they're going to digest that blood and the urea will go up, which is a like a kind of metabolism, metabolite product, byproducts of blood and it's um ingestion and digestion. You can do a breath test for helicopter back to Pylori and then you have to stop PPI for two weeks and then you can have an O G D like a scope. And the treatment for Helicobacter Pylori is going to be eradication with pack or P M C. And those are the names of the things you give. The P is a PPI like a proton pump inhibitor like omeprazole, lansoprazole. The A is either amoxicillin or I think metroNIDAZOLE and the C is Clarithromycin. So it's basically a PPI with two antibiotics and you can also give H two R S which are H two receptor antagonists. This is a column which is my favorite column in the world. I used to be so obsessed with this journal and this condom which is called images in Clinical Medicine. You can google it. Basically, it's like one of the most prestigious journals in the world. And they publish like two pictures a week which are just really nice medical images. And these are the radiological signs of pneumoperitoneum. So this is like quoting from the paper and there are much more scientifically, I'm not talked about. So it's a ra cumulation in the right upper quadrant, the subphrenic area and ventral surface of the liver. So what they're saying is solid white Irish. So that is air under the diaphragm, which is what we said earlier, the faster form ligament sign which is visible as a longitudinal linear density on the ventral surface of the liver. So that's there. I don't know if that projects very well, but basically, you have the fast form ligament, you have air pressing up against it. So you get a silhouette like we talked about earlier, the ligamentum Terry sandwiches visible as a linear density running along the inquiry edge of the falciform ligament, which is these and regular sign, which is, as we mentioned earlier, visualization of air on both sides of the bowel wall. Can you see that see that you can see the bowel really nicely the outside wall of the bowel because there's a rule inside and outside. So uh that is actually all on Abdullah X rays and their associated conditions. Can I ask what I'm gonna do is put up this SBA, which is moving into like hypoxia billary and I am going to stop at exactly 50 path. So, can I ask that you put in the chat, the feedback form? And what I'd like you all to do is I'll give you like a minute and a half to do this SBA slash start filling out that feedback form. I'd really appreciate it. Uh I've just started as a radiologist and we are required to do to teaching sessions here for our portfolio. So I'm hoping to use your feedback to progress in my radiology training. Uh It's not that deep but like I just need to show that I am teaching, however, because I've done finals course before, I've got like 30 hours of teaching content. I have ready to go and I'm hoping to start teaching medical students at ST George's because I work there. So hopefully one day I will teach you all some more if you're interested. But yeah, if you could all fill out that feedback from and I would ask for as much detail as possible. If you thought something was good, please put lots of detail. Why if you thought something was bad, please put lots of detail. Why? And I can try and improve and I'll give you all like 30 seconds to like either open that link. If you've been sent it, hopefully we'll start filling that out a little bit and also answer this question, we will stop at exactly 50 past. Uh I am fasting so I do want to stop on time so I can eat. Maybe I'll give you a couple of minutes. I don't need that and maybe I'll stop at 51 past because I'm proper generous like that. Uh And then yeah, sorry, I don't really have time for questions. TBH. But I don't think that they're that important. If you have any real like pressing questions, you can email me. And my email address is M A dot L I one NHS don't know M A dot A allow you one NHS top net but I assume that you won't really mean to, you can just Google stuff and with that, I'm gonna move on and just try fit in what I can in the next three minutes. So this is a let's go through the SBA A 42 year old woman attends at any with severe right upper quadrant pain. Okay. So patient's with right upper quadrant pain are like a different beast because the organs that are in the right upper quadrant of the liver in the gall bladder biliary tree. So you're thinking about different types of problems. Her vital signs are temperature effects 71 that is not a fever, but it's like low grade elevated heart rate. 96. That's a little bit higher than it should be, but it's not abnormal. The BP is a little bit low and the respiratory rate is high. That's called Tackett. Premier does normal blood tests except her LFTs, which are shown, right. So this is a good exercise for you to interpret LFTs. What is the first investigation to undertake? Now, you will know that I've already been on about doing a urinary pregnancy test. So that would be the first test to do, but it's not an option. The answer is an ultrasound of the right upper quadrant. It's not going to be in a wreck chest X ray. The reason for that is because the most likely diagnosis here is disease of the gallbladder or biliary tree and this woman has no signs of inflammation. She has no temperature. If we look at the LFTs, let's have a look at them. We can see that her A S T is raised, her A L T is raised, her out forces raised and her Gamma GT is raised. So they're all raised. So we'll talk, we'll, we won't talk about LFTs today. But LFTs can be abnormal because there's inflammation of the liver that's like called the transaminitis, which is these top to ST and LT or because there's obstruction and that's LPN Gamma GT. She has both. So she probably has a gallstone that's passed into a common bile duct that's backing up pressure to the gallbladder and the liver. She's got inflammation of the liver and the gallbladder. The common, the ultrasound shows a common bile duct which is nine millimeters. What is the next best test? I won't give you long term answer this. But as I've suggested, so you should know this like straight away either no or you don't. But the most likely diagnosis is that this woman has a gallstone and the gallstone has passed into the common bile duct and is causing obstruction. And the best test for that is an M R C P which is an MRI of the biliary tree and it's the same woman. So all these tip blood test results are the same. I'm going to keep going for like a minute or two. Actually, let's make this the last S P A I could talk for a long time about biliary tree disease and I'd be happy to. But obviously, this is out of the scope of the abdominal x rays consider that Abdel X rays the first half hour of this lecture, we'll just do this last SBA and then we will wrap up. Okay. So let's read through it. A 43 year old woman presents the any with severe pain under her right rib, which comes in waves again, this is a woman of right upper quadrant pain. She's icteric and her abdomen is very tender in the right upper quadrant. What's the most likely diagnosis? Now, this is likely to be gallstones or biliary tract disease. However, the fact that she has drawn this immediately means that she has a sending cholangitis. The reason for that this is a very good table to end on slide to end on is that this is important anatomy to remember you have the gallbladder, then you have this is like the drainage of bile. So the bile is produced in the liver, stored in the gallbladder and then released into the duodenum to help with breaking down fat and gallbladder disease is basically when you have a stone that forms here in the gallbladder and it causes obstruction anywhere in this tree. The reason that all of these were women is because there's supposedly lots of efs of people that get gallbladder disease. So fat female fertile, 40 family history and the composition of um alkali or stones in the Bolivar tree is that 20% have cholesterol, 5% have pigment and 75% of mixed. And what that means is that the majority of these stones are radio lucent. So if you did an Abdo X ray back to do X rays, you cannot see gallstones. That is really important to remember. Abdo X ray or CT, which is just like X ray and lots of planes, you can't see gallstones at all. Okay. That is the way to remember is that the opposite is true for kidney and renal stones. Renal stones are mostly calcium oxalate. So the investigation of choice, a renal stones is a CT because they're all calcium. So they will pacify on x rays. Basically, the thing you need to remember is that if you have gallbladder or biliary tree disease, you have one of three conditions. The classic history is waves of colicky pain in the right upper quadrant. If you have signs of, if you have that and no signs of inflammation, you have biliary colic. If you then superimposed on top of that, get fever or raised white cells on the blood tests, that suggests inflammation and that's called acute cholecystitis, colecystitis. So, coli means gallbladder and itis. The suffix itis means inflammation. So the difference between biliary colic and colecystitis is that now the gallbladder is inflamed. So you have fever, raised white cells if you have drawn this, that suggests complete obstruction of the biliary tree that is called cholangitis. And there's something called the Charcot triad of cholangitis. And that's right. Upper quadrant pain fever and drawn. This was welcomed. That is the end of the lecture. I am gonna go thank you very much for your time and thank you for having me. I'm sorry, I had to finish a little bit early. Thank you.