07 radiology in surgery tutorial hajhamad m msu
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This document provides an overview of the role of radiology in surgery. It discusses various radiological techniques including X-rays, ultrasound, CT, MRI, nuclear medicine, interventional radiology, and radiotherapy. It explains how each technique works and examples of their applications in surgical diagnosis and treatment. The document aims to familiarize readers with the principles and key roles of different radiological investigations in evaluating and managing surgical disorders.
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07 radiology in surgery tutorial hajhamad m msu
- 1. Radiology in surgery diagnosis and therapy Dr. Mohammed Hajhamad MB.ChB. (Egypt) M.S (Malaysia) Department of Surgery International Medical School Management and Science University 1
- 2. 12 February 2016 Objectives 1. Become familiar with the basic techniques and principles of radiological investigation 2. Understand the principles of selection of the most appropriate radiological technique for a given clinical problem. 3. Identify the key roles of radiology in the diagnosis and management of surgical disorders. 4. Understand the principles and indications for radiotherapy in surgical diseases. 2
- 3. 12 February 2016 Remember … No radiological technique replaces clinical skills. Do not base clinical decision making on imaging findings alone. “ Treat the patient and not the X-ray” 3
- 4. 12 February 2016 How are radiological techniques used in surgery? To aid in the diagnosis of a surgical disorder As an interventional technique to treat a surgical disorder or one of its complications To guide a surgical procedure. 4
- 5. 12 February 2016 Today’s topics X-rays Ultrasound Computed tomography (CT) Magnetic resonance imaging (MRI) Nuclear medicine. Interventional radiology Radiotherapy 5
- 6. 12 February 2016 History WILHELM CONRAD RONTGEN Father of radiology Invented X-ray in 1895 6
- 7. History SIR GODFREY HOUNSFIELD Father of CT Invented CT in 1975
- 8. 12 February 2016 Radiographs, the basics The five radiographic densities are in order of increasing brightness: I. Air 2. Fat 3. Fluid 4. Bone 5. Metal. 8
- 9. 12 February 2016 Radiographs, the basics Too dark Over exposure 9
- 10. 12 February 2016 Radiographs, the basics Too bright Under exposure 10
- 11. 12 February 2016 Radiographs, the basics Sharpness Experiment 11
- 12. 12 February 2016 CT scan and MRI Lamp and the desk are spinning rapidly around your finger. (experiment) This situation is analogous to a In CT scan (Computed Tomography), the x-ray tube (lamp) and the detector (wall) spin rapidly around the patient. Information is transferred to a computer and multiple images are reconstructed. CT images give the impression of looking at cross-sectional slices of the patient. MRI (Magnetic Resonance Imaging) generates cross-sectional images using a large magnetic field. 12
- 13. 12 February 2016 CT and MRI 13
- 14. 12 February 2016 Ultrasonography, the basics Piez0-electric effect Piezo (in Greek) means: squeeze. Piezoelectric Effect is the ability of certain materials to generate an electric charge in response to applied mechanical stress. 14
- 15. 12 February 2016 Ultrasonography, the basics An ultrasound wave is generated when an electric field is applied to an array of piezoelectric crystals located on the transducer surface. Electrical stimulation causes mechanical distortion of the crystals resulting in vibration and production of sound waves. 15
- 16. 12 February 2016 Ultrasonography, the basics Ultrasound: sound waves at higher frequencies than can be detected by human being (>20,000 Hz) In medicine, we use very high frequency between 2-20 MHz. 16
- 17. 12 February 2016 Ultrasonography, the basics 17
- 18. 12 February 2016 Ultrasonography, the basics Acoustic impedance (Z) is a physical property of tissue. It describes how much resistance an ultrasound beam encounters as it passes through a tissue. Acoustic impedance depends on: the density of the tissue (d, in kg/m3) the speed of the sound wave (c, in m/s) 18
- 19. 12 February 2016 Ultrasonography, the basics How difficult its for a sound wave to penetrate material? 19
- 20. 12 February 2016 Ultrasonography, the basics 20
- 21. 12 February 2016 Nuclear imaging Radio-isotops (radiopharmaceuticals) are given intravenously or orally. Then, external detectors (gamma cameras) capture and form images from the radiation emitted by the radiopharmaceuticals. There are several techniques of diagnostic nuclear medicine. 21
- 22. 12 February 2016 Examples Whole body bone scan – used to identify metastatic cancer involving the bone. Thyroid uptake scan – used to visualize the thyroid gland when disease of the thyroid is suspected. Renal scan – used to indicate the perfusion, function and structure of the kidneys. It is also used to indicate the presence of obstruction or renovascular hypertension. Parathyroid scan – done primarily to detect tumors in the parathyroid gland. Liver/spleen scan – allows for visualization of the liver and spleen. It is indicated for patients with cancer to rule out metastatic tumor in the liver. 22
- 23. 12 February 2016 Examples technetium-99m rubidium-82 thallium-201 fluoro-deoxy glucose (FDG)
- 29. 12 February 2016 Theraputic radiology Radiotherapy A clinical modality dealing with the use of ionizing radiation in the treatment of patients Cancer treatment
- 30. 12 February 2016 How Radiotherapy Works ? DNA Translocations Deletions
- 31. 12 February 2016 Types of Radiotherapy •External Beam Radiotherapy: radiation source is outside the patient •Brachytherapy: radiation source is inside the patient: Intra-cavitary (cervix cancer) Intra-lumenal (esophagus, bronchus) Interstitial (Head Neck, Breast)
- 32. 12 February 2016 External Beam Radiotherapy
- 34. 12 February 2016
- 35. 12 February 2016
- 36. 12 February 2016
- 37. 12 February 2016 Interventional radiology
- 38. 12 February 2016 What is interventional radiology? Interventional radiology is a subspecialty which provides minimally invasive diagnosis and/or treatment using imaging (ultrasound, CT, or fluoroscopy) to target the intervention and show the results of the intervention.
- 39. 12 February 2016 1. Percutaneous biopsy US, CT or fluoroscopy Random sampling or sampling of a mass Lung, mediastinum, pleura, chest wall, nodes Liver, adrenal gland, pancreas kidneys, lymph nodes
- 40. 12 February 2016 Liver biopsy
- 41. 12 February 2016 Lung biopsy
- 42. 12 February 2016 2. Percutaneous abscess drainage US, CT or fluoroscopy Aspiration or drainage tube placement Usually for infection Pleura, lung Hepatic (intra/sub), pericolic gutters, perisplenic, peri/intrapancreatic, pouch of Douglas, psoas, abdominal wall
- 43. 12 February 2016 3. Arteriography Injection of contrast media directly into arteries and vis via fluoroscopy Usually immediately precedes and intervention is angioplasty, stenting, embolization, thrombolysis Aorta, pelvis, lower and upper extremities, kidneys, gut, lungs
- 44. 12 February 2016 Aortic angiography
- 45. 12 February 2016 Pelvic embolization post trauma
- 46. 12 February 2016 13. Foreign body retrieval Most frequently guidewires or catheters Usually in the right heart or pulmonary artery Retrieval under fluoroscopic guidance using snares needed given infection, arrhythmia risk
- 47. 12 February 2016 Cholangiogram (L), internal external drainage from the L (R)
- 48. 12 February 2016 Jom ... practice
- 54. 54 Achalasia
- 56. NORMAL ESOPHAGUS DIAPHRAGM HIATAL HERNIA DIAPHRAGM *Note distended distal esophagus with herniation of gastric fundus into chest through esophageal hiatus. This allows for reflux of gastric contents into esophagus.
- 58. 58 Gastric Ulcer Barium collects in ulcer crater Endoscopic view of ulcer
- 59. Malignant Ulcer Benign Ulcer
- 62. Supine … Looking for: Gas in the rectum/sigmoid Gas in ascending or descending colon Distended loops
- 63. Erect .. looking for: free air “under diaphrams” air-fluid levels
- 64. Normal Gas Pattern ○ Stomach Always (except supine) ○ Small Bowel Two or three loops of non-distended bowel Normal diameter = 2.5 cm = 1 US quarter ○ Large Bowel In rectum or sigmoid – almost always
- 65. stomach colon
- 66. · Large Bowel ¨ Peripheral ¨ Haustral markings don't extend from wall to wall · Small Bowel ¨ Central ¨ Valvulae extend across lumen ¨ Maximum diameter of 2"
- 68. 68 An erect CXR (not AXR) is the best projection to diagnose a pneumoperitoneum (gas in the peritoneal cavity).
- 70. Other Signs of Free Air Rigler's sign air is present on the inside (lumenal side) and the outside (peritoneal side)
- 71. ERECT Ng tube Small Bowel Obstruction
- 72. 72
- 74. Small Bowel Obstruction Dilated Bowel Non Dilated Bowel OBSTRUCTION *
- 75. 75 Hernia
- 77. 77 Colon Cancer
- 78. 78
- 79. Sigmoid Volvulus “coffee bean sign”
- 80. 80 “beak sign” Barium fills to point of obstruction and twist of sigmoid colon Colon Volvulus
- 83. Chrohn’s Disease
- 84. 84 Chrohn’s Disease String Signcobblestone mucosa
- 85. 85 Ulcerative Colitis Lead Pipe Colon ahaustral appearance
- 87. Diverticulosis
- 89. 89 Appendicolith
- 90. 90 Ileostomy
- 91. 91 Gall Stones
- 93. Nephrocalcinosis •Hyperparathyroidism •Medullary sponge kidney
- 94. ERCP - Normal
- 95. ERCP
- 97. 97 MRCP
- 98. Small Bowel Obstruction PROXIMAL DILATED BOWEL DISTAL NORMAL BOWEL
- 100. Retroperitoneal Air
- 102. 102 Polyp of Transverse Colon
- 103. 103 Gastric Tumor
- 104. Tumor of Rectum
- 105. 105
- 106. 106 Tumor of Rectum
- 109. 109
- 110. 110 Pneumobilia
- 111. 111 GS ilues
- 114. 114 Pyogenic Abscess
- 115. 115 Liver Metastases
- 117. 117 Hernia
- 118. 118 Inguinal Hernia
- 119. Appendicitis NORMAL
- 120. 120 DrainageAbscess
- 121. 121 AAA
- 122. Pancreatitis
- 123. Pancreatitis
- 124. Pancreatitis
- 125. Carotid Body Tumor
- 126. Carotid Body Tumor
- 127. 127 T1
- 128. T2
- 129. 129 Gallbladder Stones + Wall Thickening
- 130. 130 Gallbladder Stones + Wall Thickening
- 131. Gallbladder Stones + Wall Thickening
- 132. 132 focal CBD dilatation in the distal part
- 134. CBD is dilated measuring 1 cm with tiny stone
- 135. multiple gallstones with mild thickening
- 137. Pathological Axillary Lymph Node
Notas del editor
- Infiltrating esophageal carcinoma. Double-contrast esophagogram shows a malignant stricture with the typical features: a markedly irregular contour and abrupt, shelflike proximal and distal margins (arrows).
- Nasogastric intubation stricture. Prone single-contrast esophagogram shows a relatively long segment of narrowing in the distal esophagus (arrows). This stricture developed 3 months after prolonged nasogastric intubation.
- Note: Narrowed lumen of gastric antrum by infiltrating carcinoma-typical adenocarcinoma – Linitis Plastica
- Note barium collection Centrally with surrounding edema.
- Normal air contrast barium enema (double contrast-air and barium per rectum) shows filling of colon with air and barium retrograde to the cecum with reflux into the terminal ileum.
- Note dilated small bowel centrally placed with air/fluid levels on upright exam.
- Proximal loops are dilated and distal loops are collapsed indicating an obstruction.
- Note hernia in right lower quadrant on both exams accounting for obstruction. Hernia is likely cause if there is no history of prior surgery.
- Distension extends to distal descending colon.
- Barium enema showing apple-core type constricting lesion with proximal dilation of colon—”APPLE - CORE” constricting lesion
- Dilated horse-shoe shaped sigmoid colon due to volvulus.
- Narrowed distal ileum due to chronic inflammation is typical for Crohn’s disease.
- pecimen radiograph shows an ileoileal fistula (arrow). Note the cobblestone mucosa and deep ulcerations associated with mural thickening (red arrow).
- Barium extends from lumen outward into diverticulum.
- Extensive inflammation, wall thickening and spasm can simulate carcinoma with colonoscopy required to confirm.
- Occasionally a calculus (appendicolith) is seen as the source of appendicitis due to obstruciton of the appendix and inflammation.
- CBD stone
- image of cholangiocarcinoma, showing common bile duct stricture and dilation of the proximal common bile duct
- Proximal loops are dilated and distil loops are collapsed indicating an obstruction. Obstruction most likely due to adhesions in a patient with history of abdominal surgery
- Pneumoretroperitoneum Large amount of retroperitoneal, mediastinal and subcutaneous free air due to perforation of sigmoid colon during colonoscopy.
- Polyp of transverse colon Round intraluminal formation in the middle part of the transverse colon adherent to the wall.
- Tumour of rectum Tumorous enhancing circular thickening of rectal wall, enlarged lymphatic vessels in periproctal fat.
- تابع
- تابع للي قبله وأوضح
- Bowel ischemia, gas in portal vein and liver Massiver ischemia of the bowel - most small bowel loops have non-enhacing wall, gas within the wall, gas is present in portal branches in liver. Perfusion changes of the liver as well. Stranding and edema of the mesentery.
- تابع للقي قبله
- Pyelocystitis, narrowing of calyceal neck, tumour of rectum Marked circular thickening of bladder wall, conspicuous hyperenhancement of the lining of bladder, left ureter and left pelvis. The neck of left middle calyx is relatively narrowed causing stagnation of contrast in medulla and cortex - this creates a sharply delinated area of persisting enhancement in the left kidney. Circular irregular thickening of rectal wall, enlarged (infiltrated) regional lymph nodes.
- pneumobilia biliarygas,CT scan of the abdomen where gas was noted in the intrahepatic bile ducts
- GS ilues 3findings: air in the gall stone in the ilum ,small bowel destention, biliary tree
- Amebic Liver abscess- CT scan illustrates large rim enhancing abscess collection with surrounding infiltration and edema
- large low attenuation abscess with numerous foci of air consistent with gas-producing organisms
- Pyogenic abscess. (A) CT scan demonstrates a heterogeneous low attenuation fluid collection in the liver consistent with abscess
- Pancreatic cancer with multiple liver metastases. CT image demonstrates multiple low density lesions consistent with metastatic disease.
- This patient had a large subdiaphragmatic hepatocellular carcinoma. Causes of an elevated hemidiaphragm are: 1) Above the diaphragm – decreased lung volume (atelectasis, collapse, lobectomy, pneumonectomy, pulmonary hypoplasia). 2) Diaphragm – phrenic nerve palsy, diaphragmatic eventration 3) Below the diaphragm – abdominal tumour, subphrenic abscess, distended stomach or colon. Differential diagnoses which may mimic an elevated hemidiaphragm are subpulmonic effusion, diaphragmatic hernia, diaphragmatic rupture and a tumour of the pleura or diaphragm.
- Hernia
- Findings: Multiple small bowel loops in scrotum due to right inguinal hernia. Compression of penile urethra.
- DISTENDED APPENDIX WITH LOCAL INFLAMATION.
- Catheter has been placed by radiologist using CT guidance draining abscess collection.
- =========== REPORT TEXT =========== C.T. SCAN OF NECK: I.V. contrast enhanced scanning was performed. FINDINGS: A well-defined large heterogeneous, intensely enhancing lesion noted in the right carotid space measuring about 3.7 x 4.1 x 5.8 cm with internal cystic areas. The lesion is extending between the external and internal carotids and reaching the right thyroid inferiorly. Both the carotids and the right jugular vein are displaced laterally. The right external and internal carotids and the right common carotid are patent. Few small subcentimetric lymph nodes noted in bilateral posterior triangle, the largest measuring 7.5 x 6.5 mm in the right posterior triangle. Incidentally, there is mucosal thickening of the right maxillary sinus, the right ethmoid and mildly in the right sphenoid sinus. No obvious bony abnormality seen. Included sections of the brain appear unremarkable. The thyroid appears heterogeneous, to be correlated with ultrasonography. CONCLUSION: Intensely enhancing lesion in the right carotid space most likely representing carotid body tumour.
- Carotid Body Tumor
- gallbladder stones with mild gallbladder wall thickening
- Acute Cholycystitis
- FINDINGS: There are multiple variable sized gallbladder stones with mild gallbladder wall thickening. There is focal CBD dilatation in the distal part measured about 6mm , but no CBD stones no intrahepatic biliary tree dilatation . Tiny stone seen in previous study not seen in current study.
- FINDINGS: There is 1.9 x 1.7 well defined anechoic liver lesions seen in the left lobe of the liver and shows no vascularity on color flow Doppler, likely representing simple liver cyst. No other lesion is seen. There are multiple gallstones with mild thickening and layering of the gallbladder wall measuring 3 mm. No pericholecystic fluid. Sonographic Murphy's sign is not reliable as the patient has taken analgesic. The CBD is dilated measuring 1 cm with tiny stone noted in the mid-portion measuring 0.4 cm. Mild intrahepatic biliary duct dilatation. Both kidneys are normal apart from two simple renal cortical cysts noted in the upper pole of the left kidney, largest measures 5 x 4.5 cm and and one parapelvic cyst in the right kidney measuring 1.2 x 1 cm. Pancreas is partially visualized due to gaseous abdomen. The spleen is unremarkable. No free fluid. The prostate is mildly enlarge, measuring 28.7 cc with normal echogenicity. CONCLUSION: Findings described above are likely representing early acute cholecystitis, for clinical correlation.
- FINDINGS: At around 9 o'clock position of the right breast, there is a lobulated circumscribed mass, showing some areas of spiculations and some borders are not clear and irregular, collectively the mass is 3.2 x 3.1 x 3 cm in size. Heterogeneous appearance of part of the surrounding breast parenchyma. The lesion is extending to some of the adjacent ducts at the retroareolar and outer part of the breast. Some spiculation reaching the retroareolar region with retraction of the nipple. No significant skin thickening. There are no other detectable lesions although there is small nodularity in direct contact to the outer lower part of the mass. There are few pathological right axillary lymph nodes, at least two are detectable largest of which is 1.3 x 2.2 cm in size with absence of normal fatty hilum, infiltration and low echogenicity of the parenchyma. No other detectable abnormalities at the rest of the breast, specifically the left breast or axilla, which showed normal sized lymph nodes with normal morphologic appearance. Normal appearance of the chest wall muscles. CONCLUSION: The described mass at the right breast is radiologically highly suggestive of malignancy with pathological metastatic right ipsilateral axillary lymph nodes.