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OK. That's fine. Thanks Milton. Um evening guys. So uh I'm not sure. Can we start? You have enough numbers while we waiting until it just starts? I am made. Thank you. Uh I think we just start um If that's OK. So today is the second part of uh um well, so subs series um started the radiology series started basic of CT. Last week, we did a bit of introduction into the um basic principles of CT scanning, how we scan history, how we get the images and interpretation. So today, what, what we've decided to do is just to bring a few um acute ct cases for us to have a look at discuss and just look at most of them will be stuff we are familiar familiar with. Um But I I didn't really see any specific question. I just went easy, made it easy for myself. I'll just share my screen if you guys don't mind. Uh Just give me a minute. Mm OK. I guess see my slide. If anybody can put in the chat box that you can see my slide can see the effect of, can anybody see my screen? I think I just went to now um if anybody can put in the chart book that they can see my screen. Uh No, yeah, you can see. Thank you. Thanks much time. Ok, that was scary for a minute. Uh If you can't see my screen by any time, mostly ask my phone number or anybody can just call and shout um and stage and I would just stop and pause because I can't see the chat box if I put up my slides. Um So like I said earlier, we just talk about some common acute ct cases. Um Most, most, most of them are common stuff. Most are surgical cases. Um Most of them are surgical cases. Just a few, I think one or two medical cases, but they are mostly just acute emergency stuff. Um So the first one is sub hematoma uh going starting from the uh cases. Um I'll be talking more on the ct findings. I won't really dwell into the pathology or management. I know this is surgical choice group with cost of time. I want to look at a few cases I won't really dwell into uh or dive into pathology. Such it just relevant pathology to interpreting the images. Uh So the first case is sub hematoma and just a bit about the meninges and the mening covering of the brain. So the meninges is fibrous covering of the brain is four layers. Now, commonly three layers. Um We have the Arachnoid layer parameter. Um Two guys is the outermost which lies just Benes the um sco and the Arachnoid is the middle and the P MRI is this transplant one that just lines um the brain and kma um why this is important? It is important to um identify and it helps us to identify this type of um extra axial bleed. We are looking at on CTV uh and uh sub hematoma, it's collection of blood in the sub space. The sub space potential space which is located just beneath the and between the and the aida it beneath the jura, this is a potential space which lies between the jua and the uh layer. Um So with regards to CT scanning and you co subdural or um patient is common commonly following the fall in elderly patients, commonly with confusion, we're not sure if you had the fall or not. We worried about we bleed in the brain technique. We do is a CT non contrast like we said yesterday because contrast is going to um just mo the waters and we're not going to show if by looking at the bleed or we're looking at contrast. Um This is just talking about subtypes of sub hematoma, acute subacute chronic, acute on chronic, between acute and clinic. Clinic is anything above three weeks, acute is 1st 33 days. Rule of three is to know it and between to 21 days. Subacute why, why it is important? You know, um last week, we were talking about density of different materials, acu so a blood is um coagulated blood too. Fresh blood is iden but chronic blood blood has been there for a while. Um is no more density is a bit more iso or ipos. And that's why we have to be aware of the different subtypes. And we can have acute on chronic cause with chronic subdue patients are at risk of weed, we bleeding and you can have acute bleed on top of the chronic bleed. Um This is what I was explaining in reed, we have an IPO Cosentyx shaped extra axial collection. And in clinic, we have this ipos collection instead of iden um just bit more on the meninges. Um I um sub know to cross the lines but they don't cross the midline. Why is this um cause this ate the maam. It just follows the reflection of the a and cause his um suture lines because the is not um a by um the lines, the different um suture, the and but it it, it, it is, it can cause the midline because we have the reflections in form of the fox cerebri and the 10 2 cerebellar and posteriorly. So if you're looking for or checking for sub hematoma, make sure to check the folks and the 10 2 because small be can just be there. Let me just go to the case, look at a few cases to explain what I was saying. So this is a an example of um patient who is presented follow in the form. So we can see and this iden consent shaped um um collection just lining the skull um and it cross the suture lines, but it can't cross the midline because we have the four ce in the middle, there's a bit of midline shift here and so far sign and on the right side of the brain is just been shifted to the left here and drawing a line midline from top to bottom. You can see the bit of the right side of the brain branch just shifted to the other side there. Um Confirming on gi you can just see the breath there running uh the along the folks there and you can confirm on corona which shows it much more beautifully to see this cosentyx shaped which follows the shape of the uh skull and the brain. And you can see just this liver along the fault of the sub hematoma. Uh see another one just this just to show Aone Clinic. Uh This was I was explaining Aone Clinic. You can see this um iden collection with an dense um collection within it. So patients most likely is that the chronic subdural both cause of weed in the oven acu clinic uh sub collection. So report in this collection, the collection is not just this bit that is the sub I actually from here. So that mix of the sub IMA and this just showing what I was explaining with. You can see um hyperdense collection just lining the with the and this also patient, he also has a bit of force and with the left side of the brain being shifted to the right here, bring up the axial collection, you can also see uh a axial slides, um apologies can also see a sleeve valve, please just lining the tanto cerebellar. Yeah, and also just see um hypertense collection lining the and the acute chronic subdural hematoma. On the right. Ok. I think that's basically it with identifying subdural hematoma. Um Next is extra jugal hematoma. So this is the another common border of uh in cranial bleeds. And this is collection of blood in this space between the inner layer of the skull and the outer surface of the Jura, which is another potential space called the extra dural space. So, unlike the subdural space, which is the space underneath the Jura, which follows the flexors of the Jura and the comes down and follows the lining of the dura and follows the contour of the brain and skull. The extra Jugal Limato. On the other hand, is usually due to um injury to the inner surface or inner layer of the skull and cause the degree reflections are restricted by sutures. The bleed does not cross the suture line but can cross the midline cause this collection of blood. It can just pull down this reflection and this collection can just move over to the left side. Sorry. So extra Jugal emo, which on the other hand, does not just form this cosentyx shape and follow the curve of the brain in it forms a lemon or L form shaped collection which is also hyperdense cause it blood. Um extra jugal hematoma is usually commonly um caused by an arterial bleed and usually there's always associated fractures. So the blood is always of higher pressure and most times they are not, they need uh surgery too uh to manage extra jugal hematoma. In sub jugal hematoma, most times is usually caused by just a rupture of the uh bri cortical veins and it's just venous bleed and which is usually most times the the two without surgery, but sometimes you need surgery to Eva depending on the various uh clinical presentation. Uh So that's all what I was just explaining. Yeah. Um So extra dual my usually associated with a fracture. It's an hyperdense lei form shaped collection that does not cross the suture line but can cross the midline and technique similar to any blood in the brain is with a non contrast CT head. Yeah, just bring up a case that I got here. Um So this see this lemon shaped left sided hypodense collection with uh mass effects and midline shift. You can see e ment of the hospital on or the posterior one of the la ventri and even the um an to ho is squished. Yeah, compared to the other side. So this is causing a bit of mass effects. And if you go on the bone, you will see there's always an fracture associated with it uh which usually causes injury to the middle meningeal artery in most cases that causes this this uh bleed. Ok. That my percentage on. Yeah. OK. Um So I just bought a picture explaining uh extra dual sub um So extra lemon or LTI form shaped sub lema is cosy or banana shaped. I know they say by convex by concave, I, I personally, I get confused with convexity and cons. So I just use lemon shaped and um banana shaped. I don't if that's you for anybody else there um looks like I'm moving on the good pa, just move on to the next uh third common into C which is subarachnoid hemorrhage. Um So still on the meninges and Meninga covering um subarachnoid MG which is accumulation of blood in the subarachnoid space and subarach space is the space underneath the uh aid layer. It's the space that usually contains CS F. It's um close proximity with the parameter and just lines the. Um So I, so I um so usually we see the blood um just, we see dense layers of blood just lining the ci of the brain um technique similar to any bleed in the brain is a non contrast. Um The two big um cause causes of subarach edema, which is either can either be traumatic or spontaneous. Um, traumatic is self explanatory for spontaneous numerous causes for common. Commonest is the rupture of aneurysm in the circle of Willis. So in CT findings aside, the fact that we see this um hypodense material lining, the subarach space might see evidence of an aneurysm which can be quite difficult if the bleed is, is quite massive. But we just keep an eye out to see if we can see any obvious aneurysm. Most times they tend to do a CT angiogram, which is a ct with contrast to how we look and assess the um basis of the brain properly to investigate prior to management. Uh just see a case. Um this is quite common. So just a case of so a which you can see the blood um lining the um the so side this is the circle of w with blood there looking here closely, we can see this rim of hyperdensity here. Most likely the aneurysm might be here in the right middle cerebral artery. But it's difficult to code really. Then usually you need the CT angiogram to um assess and further investigate. But you can just see hypertense material lining the so side in the brain, this is quite widespread, might not be this, but you might just see just one year lining or one year lining. So it's just, but it's quite clear, see hyperdense maga, which is blood lining d um the source and filling the basal system in the brain. This is subarachnoid uh H and just a bit of um bit of anatomy cause the cause the blood lines, the CS F spaces which is the subarachnoid space. The blood can track into the ventricular space and cause a bit of um hydrocephalus. Um So, e sign of hydrocephalus, we see in CT brain is dilation of the temporal ons of the lateral ventricles which are this um black iden structures here in the temporal lobes. So, if you see this, you shouldn't see this, this dilated. So this is an early sign of hydrocephalus. Then we get it's tracking up to the lateral ventricles, the third ventricle, there's a bit of blood here in the third ventricle actually. Uh So I think that's where the blockage is coming from. Um blood just you shouldn't see this in the, this is the third ventricle. You shouldn't see this hyperdense material in there and this fourth ventricle looks fine. Um And these are the basal systems, blood shouldn't be there. So the blood is blocking the flow of CSF which leads to be a common complication of sub blood in the form of hydrocephalus. OK. That's it. Is there any questions at this point? I've been rattling on for a while but I didn't pa to see if anybody has any questions on the chart. Can you hear me now? Yes, I can hear you too. Oh, ok. Uh No, no questions that I can see. Oh, questions. That's fine. I'll just continue there. Um So we're done with bleeds. Um This is medical, this is really surgical, but it's also a common um common um acute presentation and one of the most common reasons why we do CT scans. To be honest, most of the CT head we have done usually for a rule out stroke. Um So common patient presents with acute neurological deficit. Um We're not sure what's happened, we're not sure of the time. So I be sure of the time and we need to get a CT A to confirm a rule out the stroke. Um The technique done at first stand when the patient presents with acute neurological deficit, it a non contrasted and the non-contrasted is not actually to confirm the stroke. What, what what CT is done for really is to rule out a stroke in form of a bleed. Um where if there's no bleed, then you can give your um anti um anti thrombotic treatment aspirin depending on where you work guidelines. Um Then see if we can check for any early signs of ischemia to see if we can refer the patients for thrombolysis or thrombectomy. And to check for stroke may, is really because patients may present an acute neurological deficit, but it might not be a stroke and it might be a tumor or any other stroke may make causing the acute neurological deficit. So if you get a CT head and patient has fluid um IPO density, which is C sign, um CT head sign of a stroke, it's, it's a bit quite late. It really and the tissue can be salvaged again. So we're not really working towards that or working before that. So, um c findings of an ischemic stroke one, in fact, the earliest sign we look for is an IPA dense ves sign. um cause the um the how would I explain this? Yeah, cause the thing causing the stroke is a clot in the vessel. And um blood clots are uh hypodense. Normally in the vessel. You shouldn't see any hyperdense structure. It's just like bleeds, vessel bleeds are hyperdense cause they have clotted. So, clots in the vessel is going to show up hyperdense. So that's the earliest sign of um stroke we see in CT that's what we usually look for. Then other signs that come up with loss of gray white matter differentiation. Um We can have hypotension of the nu or hypertension of the brain matter and hypodensity generally with swelling and gal replacement. When it gets to this point, the tissue is gone and it can be salvaged most likely. But in this stage, this is when they usually have the thrombectomy or thrombolysis based on the time they presents according to guidelines. Um I got it quite interesting to me. I guess it's open. I should close all this. I got quite an interesting case that explains the den sign. So bit of um anatomy. Uh so this is the frontal lobe of the brain, see micro. So coming down chicken for in hypodensity really, uh we can see hypodensity, yeah, obvious asymmetry from the other side. So this is the level of the basal ganglia. This is the end of the coded nucleus. This is the internal capsule, anterior limb and posterior limb. Uh this is the lentiform nucleus. This is the external capsule and this is the insula bone. So this hypodensity in the insular cortex, part of the post of the external capsule and the lens for nucleus, see if we can see any um vessel abnormality go down to the level of the circle of Willis. These are the PCA um silla coming up to the PCA. Um This is the right, middle, cerebral and left, middle cerebral artery and these are the Antero cerebral arteries. You can see how these vessels are looking, they're looking like vessels obviously tubular, but we can't um we can't see any hyperdensity inside them. Um But if you, if you, if we follow the um left MC A can see just this hyperdensity, which is which is the hyperdensity is continuous in the level of the M two. So the vessel should be this way, not this way. So there's evidence of the clots in the, in the left MC and that's the hypodense ves sign. I was talking about the ves normally should be uh I see should be this way and not that way. Um We have both sides to compare check for asymmetry cause it can be quite difficult. The vessel can have um um ves can have um plaques and you might have densities that I did before, but you have both sides to compare. And if you have something that is quite um long segment and things like that S sign and this also corresponds with area of uh MC A supply in this side to be sure this is um a left MC A in fat. Uh Then obviously in this, in this um in this scan, we were going to check first for any obvious bleeds or he morg before thrombolysis or thrombectomy. And after this, this, no, so we just up, it is just, and the left MC, in fact, I'm just send to IR or neurology or stroke based on where you work for, for the treatment. OK. Um That's, that's, is there any questions on the hyperdense versus sign? No, just moving down. OK. I think that that's all with the new. Um just I just try to pick um common stuff in the head. Ct head is commonest c um modality that is done really uh quite a lot of stuff we can go into. But I think we just leave it that, that um because we have to do all that stuff. So I talked a bit about pulmonary embolism in the last, in the last lecture. Um but I just bought the, I just bought a case of pe because it's a common um surgical complication. Most surgical patients uh are usually on bed and pee is a common uh surgical complication. So technically, like we all know is CT pulmonary angiogram. We want the contrast in the pulmonary artery and we do the CT scan. That's why it's called a CT pulmonary angiogram. Uh and CT P can be a acute or chronic, they won't be bothered about this acute p not chronic P. Uh And what we're looking for is filling defects in the pulmonary arteries. Uh and the filling defect in the pulmonary arteries won't really cure the patient. What kills the patient is the cardiovascular compromise. We are looking for any evidence of white heart strain and or pulmonary hypertension, pull them inside. It's just a radiologic cru sign of um of AQ be and it's just the, I don't know if you know Polu means the black bit in the middle is the, is the feeling in the effects by the white bit surrounding is the contrast in the glo like artery. So I got it quite, quite beautiful um image that shows uh MP uh so bit of anatomy. Um this the um to put um SVC and you can see a bit of um can see a bit of filling the face here which, which just um explains where the clot is coming from, is coming from somewhere in the low bone and the pa um and the main, this is the main, sorry, my computer is skipping this, the main pulmonary trunk, right? Mean pulmonary artery, left, main pulmonary artery. And what what, what, what you, what we do is just follow the different branches and follow it up. Obviously, we can see the fill in the already but just explaining for that, I have to follow it up to see the extent of the clot. This is going further into the left um upper lobe and left lower lobe. Um pulmonary arteries is widespread p to be honest. Um So also on the right side, you can see the filling defects just all over um all over the pulmonary arteries and P potential. What we measure, we measure the ratio of the main pulmonary trunk to the ascending aorta. The ratio should be less than one, meaning the aorta should be bigger than the pulmonary trunk if it's more than in this case, this is evidence of pulmonary hypertension. Another thing we check for is evidence of vita strain. Um evidence of vital strain. We look at the intraventricular septum. Uh the left ventricle is bigger, more muscular than the right ventricle. So the intraventricular septum should ideally bulge towards the right ventricle and the left ventricle should be bigger. In this case, it's not the case. So there's an evidence this is this, there's a bit of straighten of the intraventricular septum. There's an evidence of vir strain and that sign of right eye strain is when you see blood, um we fluxing down into the IVC. This is the IVC in the liver, intra hepatic IVC and even refluxing into the hepatic veins. There's an evidence of right and strain meaning blood is refluxing from the right ventricle into the right atrum upward into the IV C and into the um systemic circulation. After checking on the, I check the upper abdomen or um solid organ, see any evidence of malignancy, check the lungs for any evidence of uh malignancy just to see if you can find it cause if cause of the pe is on know. Uh In this case, I think there was, there was some consolidation in the lung but I think this is just from um in fact, from the pe so the lung, um tissue is already dying here. This, in fact, lung infarct one here. I think that's, that's it from p point of view. Uh uh Is there anything else I can show you any form of anatomy? No, not OK. That's it. I question any, any questions on pe I have the question. Yeah. Yeah, that's um right hand strain. But yeah, the, the right um ventricle looked quite bigger than the left. Yeah. Yeah. So. Oh sorry, let me, I didn't let you finish. Sorry, apologies. Oh, yes. Uh Bobby is like more of an active game. Like, what makes it radiologically bigger because I don't think in reality it will be bigger. I don't know if you get what I mean? Because it's like an, a event. The right should not be honest. Yeah, I get what you mean with the, to be honest, I'm not sure. But, um, I think, I think it depends on the, the volume of the clot, to be honest because, um, the main fear with A P is the, um, um, cardiovascular compromise and right eye strain is a common complication of api, don't know if it's, I don't know why it's happened so quickly, but it's just a common complication. Now, I try not to about that, to be honest, but I'm, I'm, I'm assuming, I'm assuming, um, the pulmonary trunk is not actually one of the biggest, but it's quite a big, um, vessel. And if it's quite blocked the pressure, the pressure defense might be quite much. Maybe that's why it happens quite quickly. Trying to give an example of the, I'm not sure. Maybe balloons or something. Yeah, maybe a balance. How, how do you differentiate IVC from SVC? So, um, the, this is the, um, we just follow it really. Uh, you follow the track. So this is the S BC, the S BC drains into the right at RU. Yeah. And if you follow it upwards, upwards come up, I don't know if this goes up far enough. Follow it. Follow if you follow it upwards, it, this the, as that goes, when it should come up, a it comes, it comes up into the uh trunk, this is the left and this is the right. So it's just following it really. And the IVC is from inferior comes from down. So the cost of the IVC SS from the legs into the abdomen goes into the liver and tripathy IVC and that comes up, comes up, comes up to enter the. So it's just falling initial and knowing the anatomy and how they follow the cost. Really. Um I don't know if that, that explains your question. Yeah, I think that's fine. Any other questions? You're welcome. Bye. So let's move on to um next door. The next one is OK, we've gone into the abdomen now. Uh So another common um acute um surgical presentation is appendicitis. Um We don't know appendicitis is um acute inflammation of the appendix. Um It's quite common surgical presentation. It's very common in common. It's very common in young patients. Um It's, it's very um problematic for emergency doctors who ruling out appendicitis and ovarian torsion or ovarian abscess in young females. And this strike between gyne and surgeons as you admit. Um It's also common in pronounce men. Also, I think a acute appendicitis is one of the commonest surgical presentations in pronouncement. So the lots of, lots of uh it we we get lots of ct request for a appendicitis um in young patients and technically is CT with contrast because you need the contrast to delineate between the fat in the abdomen and the bowel really, especially in very um low b. And the patients with flat toy ra, they develop lot of ab fats because um fat is our find in e so ct findings in appendicitis is just the main thing is to identify the appendix really because it can be very difficult to identify the appendix and check for any peri appendiceal inflammation or any what we call fat stranding um around the appendix and the appendix will be, will be distended, which can be, which makes it more difficult to identifiable. The appendix is a blind ending structure. So if you can follow it and you see it terminates, you show you're not looking at the small bowel or you're looking at the appendix and you can, you might see an appendi it, which is like a calcified structure calcified from um fecal matter, calcified food matter that just blocked the entrance of the um appendix from the c which cause the appendicitis really. And what you're checking for is to check for any non announcement of the wall which suggests necrosis, which, which is, which, which helps the surgeons to determine if they need to go and take out this um appendix or not. If it's, if it's non, they might think if it's an properly, well, they might decide to just sit on it and avoid going into surgery. So I think my case on appendicitis, how this case loads up because it's quite large. Um, it's quite large file. So, um, identifying the, this is non contrast scan, we identify, I just want to use this to explain, I identify the appendix. What you're looking for is the scum. Um, the sitcom has two structures leaving it the distal ileum and the appendix. So you're looking for a blind ending structure that leaves the sitcom. Um Best way to look for the sitcom is to go from the rectum. Go from down below. I don't think this goes up, go from down below. You follow the sigmoid to the ascending, descending other. So I should follow this with my uh so this sigmoid to the descending and follow it up to you get to the splenic Flector and get to the transverse colon and you come down to the ascend and, and get to the, then look for two structures. The one that is blind ending is the appendix. Uh Yeah, we can see two structures leaving. This is one here. This is one year. This one here follows, follows, but it joins up with other structures. We make sure that's not the appendix, but the other one is this one which just comes out here and just comes here, comes here, comes here, comes here, comes here and terminates. You don't see the can, that's the appendix. So that's how we identify the appendix. And sit in um and to, to uh check for be really, you need a contrast scan. This patient has low BMI. Um So they've given a bit of or contrast. You can see the fats here. It fat, like we said is black, it's uh iden, it's less dense than fluid. It's closer to a, than anything. So the, the fat in the bowel should be this clean if it's dirty like this, that's what we call fat stranding. It's a sign of inflammation in the abdomen. So you can see the appendix which you identified earlier just to confirm for you because I was giving you fis this, the C is the app leaving, it's leaving, it's leaving, it's leaving, it's leaving it, leaving, it's leaving it and it just disappears. So that's appendix. So the appendix is thickened. It shouldn't be this thickened. It should be, the caliber should be less than nine centimeter is about 66 millimeters really. But this is too wide. This is about found to guess about 1.5 centimeter is about 15 millimeters and it's fluid food, it's just fluid in, it shouldn't be that the wall is also thickened. There are signs of inflammation. You can also see some surrounding lymph nodes, dis things that just in popping in and out. There are rounded, shaped with fat inside, it's fatty hyalur, those are lymph nodes. So surrounding lymph nodes. So that's classic sign of the appendicitis. So about the non non enhancing wall, this wall that is thickened. If it's looking, um if it's looking darkish, that's no, is looking not happy, then that's no answer. And that's a sign of necrosis. If you can see gas in the wall, which is what we call the pneumatosis, that's also inside mean the the the appendix is dying and that needs to come out. Uh So this is just classic uh appendicitis. Uh nice, wonderful picture you can see very well on Coronal image cause the actual image can be very difficult. This is very easy to see but see this is sitcom here. Sitcom is usually end, right? You just follow it only for your ble and the structure, this structure that good in here and this, that's the appendix. OK? Um Any questions go to the chart box. No questions. Yeah. Yeah. Good. Next one. Oh So the next one is small, small bowel obstruction. Um I think you must put this but to just put it because it's quite common. Um Power obstruction is a common presentation. Um Patient on the would not pass bowel for a while, distended, bowel, the passing gas and not passing gas. We're not sure if it's in this obstruction or not. Um Small bowel obstruction is the commonest. About 80% large bowel is fairly less common. Most times they get, they get an xray first, just everybody gets an xray f instead of just radiating everybody with sitting and what we see is dilated bowel loops. Then we show, oh, this might be a small bowel obstruction. And we get sitting, why we get it is to check for any trans point to see if there point where the K is the point where the ob, is that what we call the trans point? And how do we know he's dilated this? I don't know if we've had the x-ray series yet, but in the X series should talk about the um abdomen and identifying the various um bar it, large bar or small power. So small power should be three centimeter maximum in diameter, large Barre um six centimeter in diameter and C is the largest which is nine centimeter in diameter. So if anything greater than three centimeters, we see, oh the small bowel or anything like that. Um And we also know is small bowel, small bowel is centrally located small bowel countries. So conven unlike the last bar with countries or strong market. So I'll show you that when we go on to the case is um and the commonest causes of small bowel obstruction is additions. Um or malignancy. I shouldn't really be saying that on the surg cause most of you get a surgeon to be surgeons and in developing countries, E is known to be the commonest cause and in developed countries, additions is the commonest cause technique we use is ct abdomen and pelvis with contrast, we use contrast always cause we want to get the, get a good uh differentiation between the fats in the bowel and the, the fats in the abdomen and the bowel walls. Really. Um, ct findings dilated, proximal bowel loops loops proximal to the point of obstruction. We're looking for the transition points get dilated, proximal bo bowels proximal to the point of obstruction. You see collapsed or you actually see normal loops distal, then you see a small bowel physi sign. This is a very good sign to, to confirm obstruction. You don't really see a physis in the small bowel. If you see fes in the small bowel, it's a sign of, um, small bowel obstruction, closed loop obstruction is when is when the obstruction is at two parts. So, obstruction can be just one part or two parts. Loop obstruction is quite, uh, more serious because if a segment of bowel is pinched on both sides, then there's no proximal or distal point of, uh, what is the surgical term to, to decompress the bowel? So the bowel is at higher risk of ischemia, strangulation and ischemia. So, if we see a small bowel obstruction, one thing we always check for is to check if it is a closed loop or a single loop or an open loop obstruction. So, um, I got two cases. One just showing obstruction. I'm monitoring NICUs loop obstruction fa OK. So, like I was explaining. So this is just starting from on top. Ok. Patient, um, an open bowel in a while, get to a CT abdomen and pelvis really with contrast in the post venous face. So a bit of anatomy, this esophagus is dilated, the stomach is massively dilated. So this patient is at risk of aspiration. So this is something we always check first and we notify the clinic sign the report that this patient is at risk of aspiration. Um, we follow the stomach and sorry, um um to the duodenum downwards duodenum cause is over here and you can start to see this dilated loops of power. You're not sure. Is that transverse color or small bowel show small bowel because most the other dilated loops here which are centrally located. And you can see this, uh which are lines which one through small bowel unlike mechanism in large bar, which is which, which are just circulations and they want, they don't want through the bowel loops. So that's one way we should differentiate between small bowel loops and large bowel loops. I'm not measuring this, but I'm sure this is more than three centimeters. And the small bowel should don't be as large as large as this. It's also fluid filled. The small bowel is really, really collapsed like this one here. So make sure this is small bowel obstruction. Uh You should check also to see if you can see the distal end or not. Then the next thing you look for is a transition point. So you just follow this number to see where it changes abruptly from distension to a kink. And you can see there's something here. Follow it down. You see, this is an inal, so the bowel loops goes into this uh defect in the abdominal wall in the left inguinal canal and comes out this way and continues this way. Try to look for any other place where you can see a kink to be sure it's not a close loop obstruction. But so just my computer me up, you can see it, continue it this way. Continue this way. You can follow it, follow it for it. So your show is just one point is kinked. Yeah. And it's a left side in and yeah. Um bit of extra. How do I know in and not. So it's not really media and to your media to the pub to back here. I know that is a common way we know is um to differentiate and femoral femoral canal is very small contains um and the femoral vent, it's quite uh compressible. So if you see the femoral being squished in the femoral canal, you most likely certainly show the N I is in the femoral canal. I don't know if that makes sense. So the femoral canal is small. It's a small canal. If you have um loops of bowel in there, it's going to squish and um, compress the femoral vein. So that's a quick and easy way to differentiate if this is the femoral or in, instead of looking for the tobacco, it, this is medial or lateral. Just check if you can see the femoral vein. If you can see it's good if you can see it is femoral. So that is an example of small bowel obstruction. Second way to a left sided in her. The next one I brought that was a closed loop because closed loop is quite important is what we really, uh it's kind of like a surgical emergency. Is there someone I was looking at? Ok. Yeah. Yeah. So similar, we can see um central bowel loops. Um Di make sure it small bowel, we can see the like even looking for the transition point looking for where it kinks. So there's one year by the ball of kinks and there's another one. Yeah, with the power, I hope I've been able to come with you guys, but these are not the same place. This is one year you can see this one is pointing a bit towards the left and the one on top, where is it? I've lost it again. I went the other way. It's pointing a bit inferiorly. So the bowel loop is kinked in both sides and there's no proximal distal way to decompress the power. So this is quite an emergency cause the power is just going to die and die off. The colon of view is the best way to look at it. Uh So let me see if I can convince you guys here in the of view. So you can see the bowel lose some little bit of your wink. It's just gonna become ischemic and die cause blood. There's going to be vascular compromise. Um So you can see there's one loop here, this one, here we kinks off and another one yet we kinks off. Yeah. So the power is not, is not. It's, it's, it's um tighten on both ends and this needs urgent surgical management, uh or problem man to your surgeon. Uh Any questions on small bowel obstruction, identifying and closed loop obstruction. No questions. Yeah. Ok. Good. That's good. Um So I was um we will, we will stop on. I I was quite quick to be honest on small bowel obstruction um identifying and are able to do that also on that slide. I'm talking about closed loop obstruction, which is a high risk of developing strangulation or ischemia, which is quite more important than most serious than normal, small bowel, small bowel obstruction. I think we. Ok. Sorry. Um The last one is, I think this is the last one. Yeah. Uh So this is that come on um um CT request or common acute case, which most times the patient needs a CT scan because 99% of stones can be identified on the non contrast CT scan. And if you see this, what, what, what we are really looking for is to check for any obstruction. If you see there's an obstructing stone, then patient needs log review. Patient, usually it's no obstruction but they don't do anything surgically or manage anything or do the management more uh quickly if you get what I mean? So usually when patient presents with flank pain, strang to a deep, worried about a kid stone, we get a CT non contrast. So we because non contrast, ct abdomen and pelvis, yeah, cause like in the brain like explaining contrast is just going to mask the all of the, the, the stone and I'm not going to be sure we're looking at a stone. We're looking at contrast. And CT K GB is one of the easiest things to to we're looking for just a very structure in the abdomen. Your abdomen is black and gray, but you're looking for anything that just appears bright and you're checking for any signs of obstruction, which is hydro nephrosis or hydroureter. Um I I got to, I have two cases, one which is quite simple and easy. So this is showing everything just looks great. It's no contrast, no contrast in the vessels. And you can see this Hyden structure in the area where the urethra should be. We're not sure if this is a bullet, it can be ale bullet or, or or it's a stone. So we just treat it up. You can see some form of ADR nephrosis. Yeah, it is the right kidney, the right Elvis is dilated, that's hydronephrosis and you just follow it to the uh to the right ureter which is dilated, that is hydroureter to get the stone. So we're happy then check for further check for that down to see if you can see any stone, but the ureter has collapsed. So you can't really see anything. So that's an example of a non obstructing stone. I beg your pardon. And we'll check the other side also to be sure that you're not missing another one on the other side because patients can present with left sided pain, but they have both sides stones. So we just check. This is the, I'm sorry, the kidneys look for the test, which is this. Follow it, follow it, follow it, follow it, follow it, follow it. I'm sorry, follow it. Follow, follow it. Usually the one anterior to the. So muscles. This is your this tiny dot Stain. Um Just follow it, follow it, follow it, follow it, follow it, follow it, follow it. This is the um follow it. You get a deep bladder goes into the bladder, that's it. So you can see this thing here. That is not a stone because we follow the urea as it enters into the bladder. So that was a flip bull it um and you get lots of la in the pelvis fi are just like um calc calcifications in the veins. They are calcified blood clots in the veins and get the members of them in the, in the Pelvis. So that's why we follow the U because if I see this in the, in the and the UL is next to the, is that the, is that, is that stone by the this? But no, I follow the, that this way, this way, this way, this way, this way, the other case, I have actually shows lots of s and, and it's um shows the importance of following the the because you just get confused. Um So patient is presented with most times, they don't give us the side in Ed presented with left sided um flank pain. Um KCT K. Um So check you see both sides. Um There's a bit of fat trending around what I was explaining earlier. The fat here is just dirty and washing. That's the form of inflammation. You can see this tiny dot here. So that's a small um stone in the lower pole Achille. Um We follow the down. This is follow it down to see if you can see another stone there in the right, no stone. Um This is just the calcification in the um right common iliac. Follow it down for these are just bullet and veins cause this is the follow it down for it down until you get to the bladder and the bladder. Yeah, and go on to the other side. Also, this side is a bit of hydronephrosis. The reno is dilated the and the ua is dilated this is easier because you can easily follow the urea in this place and there's a bit of hydra. So you just follow the urea because this one is dilated. Obviously, there's obstruction, most likely there's a big obstruction stone but still following the urea, it is the urea. I don't know if you can see my. So this is, this is just the calcification in the left uh common iliac. This the keep following it down following the ureter. So we get to this place can see the obstructing stone here, which is causing the um hydroureter and hydronephrosis. This is a, this is just the, see how, how it lies in close proximity and it is easy to get um confused. There are lot of it. So and CK you just have to trace the urea. It's very difficult to the urea is collapsed and there's no actual ureter but just have to follow, follow, follow because colon is something and it's not, there is not, it's not, it really. Uh I think that's it. Um I've done quite, I've done, I'm sure I brought you guys enough. Um Yeah, so I think that's it. So we've talked about uh common acute ct cases. Uh just it just to stop really. We can't really talk about everything. It's just uh common stuff out, identify looking at it. Um uh wi is a very OK. Wit is a very amazing source for um for anything radiologic really. And I keep everybody and anybody dies. Speak to the, always see the page of wied. So thank you guys for allowing me to call you today. Ok. What's, what's your question? Um, thank you. That's the last, um, city, the one with the city, the city. Yes. Yeah. The, I think the one that, um, the size of stones that can cause that kind of obstruction like that ST I know you didn't like we didn't measure it. I don't measure it. Yeah, it looks small. It looks, it, there's nothing that is, um, there's nothing that is, um, sometimes it fixed in. It's not like the numbers are OK. This particular size should cause obstruction but there's, there's no fixed. Um, I don't know what I'm trying to explain. There's no one size fits all for medicine. Um, if you get what I mean, what you're looking for is any obvious evidence? Yes, it obvious this is not fibs. You can obviously see the ur is dilated. So obviously dilated. Uh, and you can see it. Yeah. Another thing that differentiates ali bullet from a, a stone is the, I don't know if you can appreciate this. This looks a bit sper than this. I, that by about, about your question is, I don't know, it looks small but it might, it might just be how the slice was caught. Yeah, it might be bigger than, you know. Um, it's just like, it's, it depends on how the picture was taken. So this might be bigger than what we are looking at in front here. But we can see it is obviously causing obstruction. So you can see, oh, it looks small, but I don't think it's, it's what, it's what you can see, you're gonna report really. And because it quite, quite sorry is quite close to the Vesico junction and the, um, distal, the Vesico junction is quite narrow. So the stone might be something that moves in and out and it might just cause a bit of blockage and kink the exits. And if you forget what I mean, so yeah, don't, we don't, you don't really look at you, look at the patient's clinical picture, not numbers really research as your numbers. This one should not cost this far is what you're saying. You're gonna report with him because I wanted to ask about in terms of the number though. I, I think in, in your eye, is it um five or six? Mm. Look at it like a, they are like there's a size limit usually in terms of especially for surgical. I don't know. It's gonna turn me down you theon. No, not the urologist. I don't know much about surgical management or treatment to be honest. Uh And then my second question, I can really go deep into the management cause I I'm not really but that sorry. I'm a, I'm a, a group. My second question actually is um I know ideally the plane CCKB are not used to diagnose pyonephrosis, but most sometimes they're able to report suspicion of advice from police came. Yeah. So it's so like, you know what I was saying? Last week, the clinical history is quite, is quite important. Um So pyrite are looking for a wedge shaped, in fact, a lot of fast stranding but looking at this, you can, you can, you can, you might be able to just uh if, if it's that severe and bad, you might be able to tell. So there is a bit of fast ran in. Yeah, first trying is just a bit of inflammation. So and in inflammation, if you see one part that looks more hypodense than normal, that and it looks we shaped, you can infer and say, oh this might be PTIs or not, it's not really the best way to look at it, but you might be able to just infer and give um find it based on what you are looking at. But that's why most times they, they say what are you really looking for and they ask for your clinical information to, to determine what kind of ct they're gonna do. But obviously we don't, we, you, you should only put on it no contrast, but you can in fact just use what does this look like? It looks red and just give AAA different. Really? Thank you. No worries. So, um pyrite is commonly we shaped, in fact, with uh perinephric fat stranding. So, in fact, it's going to be uh ipos along the kidney. Just, I just wanted to explain that along the kidney in a weight shaped. So if you see a part of the kid that doesn't look as the same of device, it's difficult to see because there's no contrast, there's no blood supply. But uh if you see anything, you can always just find if, if a differential, um any other question? Ok. No question. II, I was into uh too quick. I know I had quite a number of cases and now my anatomy wasn't too big. I was just explaining and talking without really pointing out the anatomy in some cases. Um Sorry about that, but I was able to explain the anatomy based on what we're looking at, how to identify the and appendix. And I feel I'm speaking for myself and ok, that's fine. Um Thank you guys for having me. Um If there's no more questions, I think we can end it. Yeah. And t thank you very much. Um Please just try to fill the feedback, I think last week, a lot of um feel from the email that was sent. Bye. Thank you. No worries. Enjoy guys. Enjoy the rest of your weekend. Bye bye.