Plain film

X-ray คอ

bull x-ray ถกคนพบโดย นกฟสกสชาวเยอรมนชอ Roentgen ในป 1895 รงสทน ามาใชในทางการแพทย มความยาวคลนประมาณ 0 - 01 angtrombull เปนคลนแมเหลกไฟฟาทมพลงงานสงและความยาวคลนสน สามารถทะลทะลวงวตถได และเมอรงสผานวตถ ความเขมของรงสจะลดลง เรยกวา attenuation โดยการถกดดกลนซงขนกบความหนาแนนของตวกลาง bull ท าใหสสารเรองแสงได (luminescence)bull สามารถท าใหเกดการแตกตวของโมเลกลได (ionization)

X-ray คอ

bull X-ray มผลตอฟลมท าใหเกดภาพได เมอน าไปผานขบวนการลางฟลมbull X-ray ท าใหเกดการเปลยนแปลงทงดาน somatic และ geneticbull เมอเซลลไดรบในปรมาณมากพอท าใหเซลลตายได จงน ามาใชรกษามะเรงบาง

ชนดไดด

Plain film คออะไร

bull Plain film คอ การถายภาพรงสเอกซโดยไมใชสารทบรงส ตวอยางplain film เชนndash Chest X-ray

ndash Plain Abdomen

ndash Plain KUB

ndash Etc

ท ำไมจงเลอกท ำChest X-ray

bull เปนการตรวจเบองตนทท าไดงาย และราคาถก plain film จงมกเปนตวเลอกแรกๆทชวยในการตรวจหาความผดปกตทมองเหนไดทางรงส

bull สามารถถายไดหลายทา เชน AP Lateral Oblique และทาอนๆ ขนอยกบต าแหนงความผดปกตทตองการจะมองหา

bull สามารถตรวจหาความผดปกตหลายๆอยางกสามารถมองเหนไดใน plain film เชน heartโต mass lymph node rib ฯลฯ

bull ความผดปกตบางอยางกสามารถมองเหนไดดกวา investigate อนๆ เชน bone fracture

bull เนองจากความสะดวก แมผปวยทนอนอยกบเตยงกสามารถท าไดbull สามารถใชประกอบการตรวจสขภาพ ใช monitor การรกษาหรอวาท ากอน

procedure ตางๆได

ท ำไมจงเลอก Plain abdomen

bull Plain film มกใชตรวจหาความผดปกตในชองทองเปนอนดบแรก เนองจากเปนการตรวจทท าไดงาย สะดวก รวดเรว และมราคาถก

bull เปนการตรวจแรกสดกอนทจะท า procedure อยางอน เชน barium enema หรอ intravenous pyelography เปนตน

bull เพอชวยหาความผดปกตทอยในชองทองไดอยางคราว ๆ โดยเฉพาะในผปวยฉกเฉนทมอาการปวดทองอยางรนแรง สงสยภาวะล าไสอดตน หรอมรทะล มองหาลมในชองทอง(pneumoperineum) สงสยนวในถงน าด นวในทางเดนปสสาวะ หนปนทอยในอวยวะตาง ๆ ในชองทอง รวมทงมองหาสงแปลกปลอม(foreign body)

ขอจ ำกดของ Plain film

bull ม Sensitivity และ Specificity ต า plain film ทปกตไมไดแปลวาไมมโรค เพราะความผดปกตบางอยางกไมสามารถพบในplain filmได เชนndash lesion ทเลก ๆndash lesion ทซอนอยใน blind area

ndash Blood clot

bull Plain film ทคณภาพไมดท าใหแปลผลผดพลาดไดงายbull ตองใชประสบการณในการอานคอนขางมาก

Chest X-ray

ทำทใชในกำรถำยภำพรงสทรวงอก

1Posteroanterior(PA)

ขนตอน ผปวยยนหนหนาเขาหาฟลมเงยคางขนเอาหลงมอแตะสะโพกงมไหลเขาหาฟลมเพอใหเงาชองกระดก

สะบกหลบจากเงาของปอด

bull ถาผปวยยนไมได ใหผปวยนงปลายเตยง ถายทาPA เอาฟลมไวดานหนากอดตลบฟลม

bull ถาผปวยนงลอเขนใหเอาฟลมไวหลงผปวย ชหมอนหนนใหล าตวอยในทาตรงถายทาAP

bull ถาผปวยอาการหนกไม สามารถลกได ใหถายทา AP supine แทน

Lateralใหผปวยเอาขางทสงสยมพยาธสภาพชดฟลม จดใหยนในทาตรงยกแขนขนเหนอศรษะ ล าแสงเขาดานตรงขามฟลม

ถาแพทยไมระบดานใดควรเอาดานซายชดฟลม เนองจากหวใจอยคอนมาทางดานซายเพอไมใหภาพขยายมากนก

ถาบรเวณทสงสยอยดานบนซงปกตจะมองไมเหน เนองจากมเงาของตนแขนและกระดกสะบกบงอย ใหผปวยงมไหลเอาแขนมาขางหนา หรอเอามอไปดานหลงเพอใหเหนรอยโรคไดชดเจน

Left anterior oblique

bull ใชเมอตองการถายภาพหวใจ เนองจากหวใจอยดานหนา จงตองถายในทา anterior oblique ใหผปวยยนเอาดานหนาขางซายชดฟลม ตะแคงตวประมาณ55องศาเพอหลบเงาหวใจแสงเขาขางหลงดานขวา

Right anterior oblique

bull ใหผปวยเอาดานหนาขางขวาชดฟลมเอยงตวประมาณ45องศาแสงเขาดานหลงขางซาย

Lateral decubitus

bull เปนทาทใชถายด air fluid level ในทานอนตะแคง โดยเอาขางทสงสยวามน าลงหรอดานทมลมขนดานบน

bull แพทยควรระบวาตองการภาพถายรงสทา Left หรอ Right

lateral decubitus เพอจะไดผลฟลมตามตองการ

Apical lordotic

เปนทาส าหรบดยอดปอดทานผปวยยนหางฟลมหลงเอนเทาชดฟลมแสงเอกซเรยจะเอยงผานใตระดบของประดกไหปลารา เพอใหเงาของกระดกนหลบไปจากเงาของยอดปอด ท าใหเหนยอดปอดไดชดเจน

หลกการแปลผลภาพรงส

1Identification

2Placing the film

3Techniques

-overunder exposure

-หายใจเขาเตมท กะบงลมขางขวาควรอยทระดบกระดซโครงชองท6ดานหนา(anterior right 6 rib) หรอชองท9ดานหลง (posterior

right 9-10 rib)

-ปลายกระดก clavicle จะหางจากขอบกระดก spinouts process of thoracic spine เปนระยะเทากนทง2ขาง

4อานตามหลกการ ABCDEF

Aairwaygtgtgt trachea

A midline structure that generally ranges in

length from 6-9cm diameter~15cm

-แยกเปนหลอดลมซายและขวาcarina(black arrow) ทระดบ -T4-5 vertebral body

Carinal angle ~ 75-85

degree

Blung parenchyma

upper lung zone เหนอ ICS2

middle lung zone ICS2-ICS4

lower lung zone อยใต middle lung zone

C Cardiac

bull Heart Cardiothoracic ratio normally lt05 in

adult

bull Aortic knob normally its caliber is ~ 3cm (

4cm in elder )

Ddiaphragm

อยทระดบICS 6ดานหนา อยระดบ ICS9-10ดานหลง

diaphragmขางขวาสงกวาดานซายประมาณครงชองของ Intercostal space

Left hemi diaphragm จะเหนเงาลมในกระเพาะ อยหางจากกระบงลม ~1cm แตไมเกน 2cm

E bone structureamp soft tissue shadows

Radiological sign

bull Air bronchogram

an air-filled bronchus against surrounding opacified alveoli It is indicative of an airspace process and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due to obstruction (as air is resorbed)

Found in

- Pneumonic consolidation

- Pulmonary edema

- Neonatal respiratory distress syndrome

X-ray คอ

bull x-ray ถกคนพบโดย นกฟสกสชาวเยอรมนชอ Roentgen ในป 1895 รงสทน ามาใชในทางการแพทย มความยาวคลนประมาณ 0 - 01 angtrombull เปนคลนแมเหลกไฟฟาทมพลงงานสงและความยาวคลนสน สามารถทะลทะลวงวตถได และเมอรงสผานวตถ ความเขมของรงสจะลดลง เรยกวา attenuation โดยการถกดดกลนซงขนกบความหนาแนนของตวกลาง bull ท าใหสสารเรองแสงได (luminescence)bull สามารถท าใหเกดการแตกตวของโมเลกลได (ionization)

X-ray คอ

bull X-ray มผลตอฟลมท าใหเกดภาพได เมอน าไปผานขบวนการลางฟลมbull X-ray ท าใหเกดการเปลยนแปลงทงดาน somatic และ geneticbull เมอเซลลไดรบในปรมาณมากพอท าใหเซลลตายได จงน ามาใชรกษามะเรงบาง

ชนดไดด

Plain film คออะไร

bull Plain film คอ การถายภาพรงสเอกซโดยไมใชสารทบรงส ตวอยางplain film เชนndash Chest X-ray

ndash Plain Abdomen

ndash Plain KUB

ndash Etc

ท ำไมจงเลอกท ำChest X-ray

bull เปนการตรวจเบองตนทท าไดงาย และราคาถก plain film จงมกเปนตวเลอกแรกๆทชวยในการตรวจหาความผดปกตทมองเหนไดทางรงส

bull สามารถถายไดหลายทา เชน AP Lateral Oblique และทาอนๆ ขนอยกบต าแหนงความผดปกตทตองการจะมองหา

bull สามารถตรวจหาความผดปกตหลายๆอยางกสามารถมองเหนไดใน plain film เชน heartโต mass lymph node rib ฯลฯ

bull ความผดปกตบางอยางกสามารถมองเหนไดดกวา investigate อนๆ เชน bone fracture

bull เนองจากความสะดวก แมผปวยทนอนอยกบเตยงกสามารถท าไดbull สามารถใชประกอบการตรวจสขภาพ ใช monitor การรกษาหรอวาท ากอน

procedure ตางๆได

ท ำไมจงเลอก Plain abdomen

bull Plain film มกใชตรวจหาความผดปกตในชองทองเปนอนดบแรก เนองจากเปนการตรวจทท าไดงาย สะดวก รวดเรว และมราคาถก

bull เปนการตรวจแรกสดกอนทจะท า procedure อยางอน เชน barium enema หรอ intravenous pyelography เปนตน

bull เพอชวยหาความผดปกตทอยในชองทองไดอยางคราว ๆ โดยเฉพาะในผปวยฉกเฉนทมอาการปวดทองอยางรนแรง สงสยภาวะล าไสอดตน หรอมรทะล มองหาลมในชองทอง(pneumoperineum) สงสยนวในถงน าด นวในทางเดนปสสาวะ หนปนทอยในอวยวะตาง ๆ ในชองทอง รวมทงมองหาสงแปลกปลอม(foreign body)

ขอจ ำกดของ Plain film

bull ม Sensitivity และ Specificity ต า plain film ทปกตไมไดแปลวาไมมโรค เพราะความผดปกตบางอยางกไมสามารถพบในplain filmได เชนndash lesion ทเลก ๆndash lesion ทซอนอยใน blind area

ndash Blood clot

bull Plain film ทคณภาพไมดท าใหแปลผลผดพลาดไดงายbull ตองใชประสบการณในการอานคอนขางมาก

Chest X-ray

ทำทใชในกำรถำยภำพรงสทรวงอก

1Posteroanterior(PA)

ขนตอน ผปวยยนหนหนาเขาหาฟลมเงยคางขนเอาหลงมอแตะสะโพกงมไหลเขาหาฟลมเพอใหเงาชองกระดก

สะบกหลบจากเงาของปอด

bull ถาผปวยยนไมได ใหผปวยนงปลายเตยง ถายทาPA เอาฟลมไวดานหนากอดตลบฟลม

bull ถาผปวยนงลอเขนใหเอาฟลมไวหลงผปวย ชหมอนหนนใหล าตวอยในทาตรงถายทาAP

bull ถาผปวยอาการหนกไม สามารถลกได ใหถายทา AP supine แทน

Lateralใหผปวยเอาขางทสงสยมพยาธสภาพชดฟลม จดใหยนในทาตรงยกแขนขนเหนอศรษะ ล าแสงเขาดานตรงขามฟลม

ถาแพทยไมระบดานใดควรเอาดานซายชดฟลม เนองจากหวใจอยคอนมาทางดานซายเพอไมใหภาพขยายมากนก

ถาบรเวณทสงสยอยดานบนซงปกตจะมองไมเหน เนองจากมเงาของตนแขนและกระดกสะบกบงอย ใหผปวยงมไหลเอาแขนมาขางหนา หรอเอามอไปดานหลงเพอใหเหนรอยโรคไดชดเจน

Left anterior oblique

bull ใชเมอตองการถายภาพหวใจ เนองจากหวใจอยดานหนา จงตองถายในทา anterior oblique ใหผปวยยนเอาดานหนาขางซายชดฟลม ตะแคงตวประมาณ55องศาเพอหลบเงาหวใจแสงเขาขางหลงดานขวา

Right anterior oblique

bull ใหผปวยเอาดานหนาขางขวาชดฟลมเอยงตวประมาณ45องศาแสงเขาดานหลงขางซาย

Lateral decubitus

bull เปนทาทใชถายด air fluid level ในทานอนตะแคง โดยเอาขางทสงสยวามน าลงหรอดานทมลมขนดานบน

bull แพทยควรระบวาตองการภาพถายรงสทา Left หรอ Right

lateral decubitus เพอจะไดผลฟลมตามตองการ

Apical lordotic

เปนทาส าหรบดยอดปอดทานผปวยยนหางฟลมหลงเอนเทาชดฟลมแสงเอกซเรยจะเอยงผานใตระดบของประดกไหปลารา เพอใหเงาของกระดกนหลบไปจากเงาของยอดปอด ท าใหเหนยอดปอดไดชดเจน

หลกการแปลผลภาพรงส

1Identification

2Placing the film

3Techniques

-overunder exposure

-หายใจเขาเตมท กะบงลมขางขวาควรอยทระดบกระดซโครงชองท6ดานหนา(anterior right 6 rib) หรอชองท9ดานหลง (posterior

right 9-10 rib)

-ปลายกระดก clavicle จะหางจากขอบกระดก spinouts process of thoracic spine เปนระยะเทากนทง2ขาง

4อานตามหลกการ ABCDEF

Aairwaygtgtgt trachea

A midline structure that generally ranges in

length from 6-9cm diameter~15cm

-แยกเปนหลอดลมซายและขวาcarina(black arrow) ทระดบ -T4-5 vertebral body

Carinal angle ~ 75-85

degree

Blung parenchyma

upper lung zone เหนอ ICS2

middle lung zone ICS2-ICS4

lower lung zone อยใต middle lung zone

C Cardiac

bull Heart Cardiothoracic ratio normally lt05 in

adult

bull Aortic knob normally its caliber is ~ 3cm (

4cm in elder )

Ddiaphragm

อยทระดบICS 6ดานหนา อยระดบ ICS9-10ดานหลง

diaphragmขางขวาสงกวาดานซายประมาณครงชองของ Intercostal space

Left hemi diaphragm จะเหนเงาลมในกระเพาะ อยหางจากกระบงลม ~1cm แตไมเกน 2cm

E bone structureamp soft tissue shadows

Radiological sign

bull Air bronchogram

an air-filled bronchus against surrounding opacified alveoli It is indicative of an airspace process and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due to obstruction (as air is resorbed)

Found in

- Pneumonic consolidation

- Pulmonary edema

- Neonatal respiratory distress syndrome

X-ray คอ

bull X-ray มผลตอฟลมท าใหเกดภาพได เมอน าไปผานขบวนการลางฟลมbull X-ray ท าใหเกดการเปลยนแปลงทงดาน somatic และ geneticbull เมอเซลลไดรบในปรมาณมากพอท าใหเซลลตายได จงน ามาใชรกษามะเรงบาง

ชนดไดด

Plain film คออะไร

bull Plain film คอ การถายภาพรงสเอกซโดยไมใชสารทบรงส ตวอยางplain film เชนndash Chest X-ray

ndash Plain Abdomen

ndash Plain KUB

ndash Etc

ท ำไมจงเลอกท ำChest X-ray

bull เปนการตรวจเบองตนทท าไดงาย และราคาถก plain film จงมกเปนตวเลอกแรกๆทชวยในการตรวจหาความผดปกตทมองเหนไดทางรงส

bull สามารถถายไดหลายทา เชน AP Lateral Oblique และทาอนๆ ขนอยกบต าแหนงความผดปกตทตองการจะมองหา

bull สามารถตรวจหาความผดปกตหลายๆอยางกสามารถมองเหนไดใน plain film เชน heartโต mass lymph node rib ฯลฯ

bull ความผดปกตบางอยางกสามารถมองเหนไดดกวา investigate อนๆ เชน bone fracture

bull เนองจากความสะดวก แมผปวยทนอนอยกบเตยงกสามารถท าไดbull สามารถใชประกอบการตรวจสขภาพ ใช monitor การรกษาหรอวาท ากอน

procedure ตางๆได

ท ำไมจงเลอก Plain abdomen

bull Plain film มกใชตรวจหาความผดปกตในชองทองเปนอนดบแรก เนองจากเปนการตรวจทท าไดงาย สะดวก รวดเรว และมราคาถก

bull เปนการตรวจแรกสดกอนทจะท า procedure อยางอน เชน barium enema หรอ intravenous pyelography เปนตน

bull เพอชวยหาความผดปกตทอยในชองทองไดอยางคราว ๆ โดยเฉพาะในผปวยฉกเฉนทมอาการปวดทองอยางรนแรง สงสยภาวะล าไสอดตน หรอมรทะล มองหาลมในชองทอง(pneumoperineum) สงสยนวในถงน าด นวในทางเดนปสสาวะ หนปนทอยในอวยวะตาง ๆ ในชองทอง รวมทงมองหาสงแปลกปลอม(foreign body)

ขอจ ำกดของ Plain film

bull ม Sensitivity และ Specificity ต า plain film ทปกตไมไดแปลวาไมมโรค เพราะความผดปกตบางอยางกไมสามารถพบในplain filmได เชนndash lesion ทเลก ๆndash lesion ทซอนอยใน blind area

ndash Blood clot

bull Plain film ทคณภาพไมดท าใหแปลผลผดพลาดไดงายbull ตองใชประสบการณในการอานคอนขางมาก

Chest X-ray

ทำทใชในกำรถำยภำพรงสทรวงอก

1Posteroanterior(PA)

ขนตอน ผปวยยนหนหนาเขาหาฟลมเงยคางขนเอาหลงมอแตะสะโพกงมไหลเขาหาฟลมเพอใหเงาชองกระดก

สะบกหลบจากเงาของปอด

bull ถาผปวยยนไมได ใหผปวยนงปลายเตยง ถายทาPA เอาฟลมไวดานหนากอดตลบฟลม

bull ถาผปวยนงลอเขนใหเอาฟลมไวหลงผปวย ชหมอนหนนใหล าตวอยในทาตรงถายทาAP

bull ถาผปวยอาการหนกไม สามารถลกได ใหถายทา AP supine แทน

Lateralใหผปวยเอาขางทสงสยมพยาธสภาพชดฟลม จดใหยนในทาตรงยกแขนขนเหนอศรษะ ล าแสงเขาดานตรงขามฟลม

ถาแพทยไมระบดานใดควรเอาดานซายชดฟลม เนองจากหวใจอยคอนมาทางดานซายเพอไมใหภาพขยายมากนก

ถาบรเวณทสงสยอยดานบนซงปกตจะมองไมเหน เนองจากมเงาของตนแขนและกระดกสะบกบงอย ใหผปวยงมไหลเอาแขนมาขางหนา หรอเอามอไปดานหลงเพอใหเหนรอยโรคไดชดเจน

Left anterior oblique

bull ใชเมอตองการถายภาพหวใจ เนองจากหวใจอยดานหนา จงตองถายในทา anterior oblique ใหผปวยยนเอาดานหนาขางซายชดฟลม ตะแคงตวประมาณ55องศาเพอหลบเงาหวใจแสงเขาขางหลงดานขวา

Right anterior oblique

bull ใหผปวยเอาดานหนาขางขวาชดฟลมเอยงตวประมาณ45องศาแสงเขาดานหลงขางซาย

Lateral decubitus

bull เปนทาทใชถายด air fluid level ในทานอนตะแคง โดยเอาขางทสงสยวามน าลงหรอดานทมลมขนดานบน

bull แพทยควรระบวาตองการภาพถายรงสทา Left หรอ Right

lateral decubitus เพอจะไดผลฟลมตามตองการ

Apical lordotic

เปนทาส าหรบดยอดปอดทานผปวยยนหางฟลมหลงเอนเทาชดฟลมแสงเอกซเรยจะเอยงผานใตระดบของประดกไหปลารา เพอใหเงาของกระดกนหลบไปจากเงาของยอดปอด ท าใหเหนยอดปอดไดชดเจน

หลกการแปลผลภาพรงส

1Identification

2Placing the film

3Techniques

-overunder exposure

-หายใจเขาเตมท กะบงลมขางขวาควรอยทระดบกระดซโครงชองท6ดานหนา(anterior right 6 rib) หรอชองท9ดานหลง (posterior

right 9-10 rib)

-ปลายกระดก clavicle จะหางจากขอบกระดก spinouts process of thoracic spine เปนระยะเทากนทง2ขาง

4อานตามหลกการ ABCDEF

Aairwaygtgtgt trachea

A midline structure that generally ranges in

length from 6-9cm diameter~15cm

-แยกเปนหลอดลมซายและขวาcarina(black arrow) ทระดบ -T4-5 vertebral body

Carinal angle ~ 75-85

degree

Blung parenchyma

upper lung zone เหนอ ICS2

middle lung zone ICS2-ICS4

lower lung zone อยใต middle lung zone

C Cardiac

bull Heart Cardiothoracic ratio normally lt05 in

adult

bull Aortic knob normally its caliber is ~ 3cm (

4cm in elder )

Ddiaphragm

อยทระดบICS 6ดานหนา อยระดบ ICS9-10ดานหลง

diaphragmขางขวาสงกวาดานซายประมาณครงชองของ Intercostal space

Left hemi diaphragm จะเหนเงาลมในกระเพาะ อยหางจากกระบงลม ~1cm แตไมเกน 2cm

E bone structureamp soft tissue shadows

Radiological sign

bull Air bronchogram

an air-filled bronchus against surrounding opacified alveoli It is indicative of an airspace process and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due to obstruction (as air is resorbed)

Found in

- Pneumonic consolidation

- Pulmonary edema

- Neonatal respiratory distress syndrome

Plain film คออะไร

bull Plain film คอ การถายภาพรงสเอกซโดยไมใชสารทบรงส ตวอยางplain film เชนndash Chest X-ray

ndash Plain Abdomen

ndash Plain KUB

ndash Etc

ท ำไมจงเลอกท ำChest X-ray

bull เปนการตรวจเบองตนทท าไดงาย และราคาถก plain film จงมกเปนตวเลอกแรกๆทชวยในการตรวจหาความผดปกตทมองเหนไดทางรงส

bull สามารถถายไดหลายทา เชน AP Lateral Oblique และทาอนๆ ขนอยกบต าแหนงความผดปกตทตองการจะมองหา

bull สามารถตรวจหาความผดปกตหลายๆอยางกสามารถมองเหนไดใน plain film เชน heartโต mass lymph node rib ฯลฯ

bull ความผดปกตบางอยางกสามารถมองเหนไดดกวา investigate อนๆ เชน bone fracture

bull เนองจากความสะดวก แมผปวยทนอนอยกบเตยงกสามารถท าไดbull สามารถใชประกอบการตรวจสขภาพ ใช monitor การรกษาหรอวาท ากอน

procedure ตางๆได

ท ำไมจงเลอก Plain abdomen

bull Plain film มกใชตรวจหาความผดปกตในชองทองเปนอนดบแรก เนองจากเปนการตรวจทท าไดงาย สะดวก รวดเรว และมราคาถก

bull เปนการตรวจแรกสดกอนทจะท า procedure อยางอน เชน barium enema หรอ intravenous pyelography เปนตน

bull เพอชวยหาความผดปกตทอยในชองทองไดอยางคราว ๆ โดยเฉพาะในผปวยฉกเฉนทมอาการปวดทองอยางรนแรง สงสยภาวะล าไสอดตน หรอมรทะล มองหาลมในชองทอง(pneumoperineum) สงสยนวในถงน าด นวในทางเดนปสสาวะ หนปนทอยในอวยวะตาง ๆ ในชองทอง รวมทงมองหาสงแปลกปลอม(foreign body)

ขอจ ำกดของ Plain film

bull ม Sensitivity และ Specificity ต า plain film ทปกตไมไดแปลวาไมมโรค เพราะความผดปกตบางอยางกไมสามารถพบในplain filmได เชนndash lesion ทเลก ๆndash lesion ทซอนอยใน blind area

ndash Blood clot

bull Plain film ทคณภาพไมดท าใหแปลผลผดพลาดไดงายbull ตองใชประสบการณในการอานคอนขางมาก

Chest X-ray

ทำทใชในกำรถำยภำพรงสทรวงอก

1Posteroanterior(PA)

ขนตอน ผปวยยนหนหนาเขาหาฟลมเงยคางขนเอาหลงมอแตะสะโพกงมไหลเขาหาฟลมเพอใหเงาชองกระดก

สะบกหลบจากเงาของปอด

bull ถาผปวยยนไมได ใหผปวยนงปลายเตยง ถายทาPA เอาฟลมไวดานหนากอดตลบฟลม

bull ถาผปวยนงลอเขนใหเอาฟลมไวหลงผปวย ชหมอนหนนใหล าตวอยในทาตรงถายทาAP

bull ถาผปวยอาการหนกไม สามารถลกได ใหถายทา AP supine แทน

Lateralใหผปวยเอาขางทสงสยมพยาธสภาพชดฟลม จดใหยนในทาตรงยกแขนขนเหนอศรษะ ล าแสงเขาดานตรงขามฟลม

ถาแพทยไมระบดานใดควรเอาดานซายชดฟลม เนองจากหวใจอยคอนมาทางดานซายเพอไมใหภาพขยายมากนก

ถาบรเวณทสงสยอยดานบนซงปกตจะมองไมเหน เนองจากมเงาของตนแขนและกระดกสะบกบงอย ใหผปวยงมไหลเอาแขนมาขางหนา หรอเอามอไปดานหลงเพอใหเหนรอยโรคไดชดเจน

Left anterior oblique

bull ใชเมอตองการถายภาพหวใจ เนองจากหวใจอยดานหนา จงตองถายในทา anterior oblique ใหผปวยยนเอาดานหนาขางซายชดฟลม ตะแคงตวประมาณ55องศาเพอหลบเงาหวใจแสงเขาขางหลงดานขวา

Right anterior oblique

bull ใหผปวยเอาดานหนาขางขวาชดฟลมเอยงตวประมาณ45องศาแสงเขาดานหลงขางซาย

Lateral decubitus

bull เปนทาทใชถายด air fluid level ในทานอนตะแคง โดยเอาขางทสงสยวามน าลงหรอดานทมลมขนดานบน

bull แพทยควรระบวาตองการภาพถายรงสทา Left หรอ Right

lateral decubitus เพอจะไดผลฟลมตามตองการ

Apical lordotic

เปนทาส าหรบดยอดปอดทานผปวยยนหางฟลมหลงเอนเทาชดฟลมแสงเอกซเรยจะเอยงผานใตระดบของประดกไหปลารา เพอใหเงาของกระดกนหลบไปจากเงาของยอดปอด ท าใหเหนยอดปอดไดชดเจน

หลกการแปลผลภาพรงส

1Identification

2Placing the film

3Techniques

-overunder exposure

-หายใจเขาเตมท กะบงลมขางขวาควรอยทระดบกระดซโครงชองท6ดานหนา(anterior right 6 rib) หรอชองท9ดานหลง (posterior

right 9-10 rib)

-ปลายกระดก clavicle จะหางจากขอบกระดก spinouts process of thoracic spine เปนระยะเทากนทง2ขาง

4อานตามหลกการ ABCDEF

Aairwaygtgtgt trachea

A midline structure that generally ranges in

length from 6-9cm diameter~15cm

-แยกเปนหลอดลมซายและขวาcarina(black arrow) ทระดบ -T4-5 vertebral body

Carinal angle ~ 75-85

degree

Blung parenchyma

upper lung zone เหนอ ICS2

middle lung zone ICS2-ICS4

lower lung zone อยใต middle lung zone

C Cardiac

bull Heart Cardiothoracic ratio normally lt05 in

adult

bull Aortic knob normally its caliber is ~ 3cm (

4cm in elder )

Ddiaphragm

อยทระดบICS 6ดานหนา อยระดบ ICS9-10ดานหลง

diaphragmขางขวาสงกวาดานซายประมาณครงชองของ Intercostal space

Left hemi diaphragm จะเหนเงาลมในกระเพาะ อยหางจากกระบงลม ~1cm แตไมเกน 2cm

E bone structureamp soft tissue shadows

Radiological sign

bull Air bronchogram

an air-filled bronchus against surrounding opacified alveoli It is indicative of an airspace process and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due to obstruction (as air is resorbed)

Found in

- Pneumonic consolidation

- Pulmonary edema

- Neonatal respiratory distress syndrome

ท ำไมจงเลอกท ำChest X-ray

bull เปนการตรวจเบองตนทท าไดงาย และราคาถก plain film จงมกเปนตวเลอกแรกๆทชวยในการตรวจหาความผดปกตทมองเหนไดทางรงส

bull สามารถถายไดหลายทา เชน AP Lateral Oblique และทาอนๆ ขนอยกบต าแหนงความผดปกตทตองการจะมองหา

bull สามารถตรวจหาความผดปกตหลายๆอยางกสามารถมองเหนไดใน plain film เชน heartโต mass lymph node rib ฯลฯ

bull ความผดปกตบางอยางกสามารถมองเหนไดดกวา investigate อนๆ เชน bone fracture

bull เนองจากความสะดวก แมผปวยทนอนอยกบเตยงกสามารถท าไดbull สามารถใชประกอบการตรวจสขภาพ ใช monitor การรกษาหรอวาท ากอน

procedure ตางๆได

ท ำไมจงเลอก Plain abdomen

bull Plain film มกใชตรวจหาความผดปกตในชองทองเปนอนดบแรก เนองจากเปนการตรวจทท าไดงาย สะดวก รวดเรว และมราคาถก

bull เปนการตรวจแรกสดกอนทจะท า procedure อยางอน เชน barium enema หรอ intravenous pyelography เปนตน

bull เพอชวยหาความผดปกตทอยในชองทองไดอยางคราว ๆ โดยเฉพาะในผปวยฉกเฉนทมอาการปวดทองอยางรนแรง สงสยภาวะล าไสอดตน หรอมรทะล มองหาลมในชองทอง(pneumoperineum) สงสยนวในถงน าด นวในทางเดนปสสาวะ หนปนทอยในอวยวะตาง ๆ ในชองทอง รวมทงมองหาสงแปลกปลอม(foreign body)

ขอจ ำกดของ Plain film

bull ม Sensitivity และ Specificity ต า plain film ทปกตไมไดแปลวาไมมโรค เพราะความผดปกตบางอยางกไมสามารถพบในplain filmได เชนndash lesion ทเลก ๆndash lesion ทซอนอยใน blind area

ndash Blood clot

bull Plain film ทคณภาพไมดท าใหแปลผลผดพลาดไดงายbull ตองใชประสบการณในการอานคอนขางมาก

Chest X-ray

ทำทใชในกำรถำยภำพรงสทรวงอก

1Posteroanterior(PA)

ขนตอน ผปวยยนหนหนาเขาหาฟลมเงยคางขนเอาหลงมอแตะสะโพกงมไหลเขาหาฟลมเพอใหเงาชองกระดก

สะบกหลบจากเงาของปอด

bull ถาผปวยยนไมได ใหผปวยนงปลายเตยง ถายทาPA เอาฟลมไวดานหนากอดตลบฟลม

bull ถาผปวยนงลอเขนใหเอาฟลมไวหลงผปวย ชหมอนหนนใหล าตวอยในทาตรงถายทาAP

bull ถาผปวยอาการหนกไม สามารถลกได ใหถายทา AP supine แทน

Lateralใหผปวยเอาขางทสงสยมพยาธสภาพชดฟลม จดใหยนในทาตรงยกแขนขนเหนอศรษะ ล าแสงเขาดานตรงขามฟลม

ถาแพทยไมระบดานใดควรเอาดานซายชดฟลม เนองจากหวใจอยคอนมาทางดานซายเพอไมใหภาพขยายมากนก

ถาบรเวณทสงสยอยดานบนซงปกตจะมองไมเหน เนองจากมเงาของตนแขนและกระดกสะบกบงอย ใหผปวยงมไหลเอาแขนมาขางหนา หรอเอามอไปดานหลงเพอใหเหนรอยโรคไดชดเจน

Left anterior oblique

bull ใชเมอตองการถายภาพหวใจ เนองจากหวใจอยดานหนา จงตองถายในทา anterior oblique ใหผปวยยนเอาดานหนาขางซายชดฟลม ตะแคงตวประมาณ55องศาเพอหลบเงาหวใจแสงเขาขางหลงดานขวา

Right anterior oblique

bull ใหผปวยเอาดานหนาขางขวาชดฟลมเอยงตวประมาณ45องศาแสงเขาดานหลงขางซาย

Lateral decubitus

bull เปนทาทใชถายด air fluid level ในทานอนตะแคง โดยเอาขางทสงสยวามน าลงหรอดานทมลมขนดานบน

bull แพทยควรระบวาตองการภาพถายรงสทา Left หรอ Right

lateral decubitus เพอจะไดผลฟลมตามตองการ

Apical lordotic

เปนทาส าหรบดยอดปอดทานผปวยยนหางฟลมหลงเอนเทาชดฟลมแสงเอกซเรยจะเอยงผานใตระดบของประดกไหปลารา เพอใหเงาของกระดกนหลบไปจากเงาของยอดปอด ท าใหเหนยอดปอดไดชดเจน

หลกการแปลผลภาพรงส

1Identification

2Placing the film

3Techniques

-overunder exposure

-หายใจเขาเตมท กะบงลมขางขวาควรอยทระดบกระดซโครงชองท6ดานหนา(anterior right 6 rib) หรอชองท9ดานหลง (posterior

right 9-10 rib)

-ปลายกระดก clavicle จะหางจากขอบกระดก spinouts process of thoracic spine เปนระยะเทากนทง2ขาง

4อานตามหลกการ ABCDEF

Aairwaygtgtgt trachea

A midline structure that generally ranges in

length from 6-9cm diameter~15cm

-แยกเปนหลอดลมซายและขวาcarina(black arrow) ทระดบ -T4-5 vertebral body

Carinal angle ~ 75-85

degree

Blung parenchyma

upper lung zone เหนอ ICS2

middle lung zone ICS2-ICS4

lower lung zone อยใต middle lung zone

C Cardiac

bull Heart Cardiothoracic ratio normally lt05 in

adult

bull Aortic knob normally its caliber is ~ 3cm (

4cm in elder )

Ddiaphragm

อยทระดบICS 6ดานหนา อยระดบ ICS9-10ดานหลง

diaphragmขางขวาสงกวาดานซายประมาณครงชองของ Intercostal space

Left hemi diaphragm จะเหนเงาลมในกระเพาะ อยหางจากกระบงลม ~1cm แตไมเกน 2cm

E bone structureamp soft tissue shadows

Radiological sign

bull Air bronchogram

an air-filled bronchus against surrounding opacified alveoli It is indicative of an airspace process and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due to obstruction (as air is resorbed)

Found in

- Pneumonic consolidation

- Pulmonary edema

- Neonatal respiratory distress syndrome

ท ำไมจงเลอก Plain abdomen

bull Plain film มกใชตรวจหาความผดปกตในชองทองเปนอนดบแรก เนองจากเปนการตรวจทท าไดงาย สะดวก รวดเรว และมราคาถก

bull เปนการตรวจแรกสดกอนทจะท า procedure อยางอน เชน barium enema หรอ intravenous pyelography เปนตน

bull เพอชวยหาความผดปกตทอยในชองทองไดอยางคราว ๆ โดยเฉพาะในผปวยฉกเฉนทมอาการปวดทองอยางรนแรง สงสยภาวะล าไสอดตน หรอมรทะล มองหาลมในชองทอง(pneumoperineum) สงสยนวในถงน าด นวในทางเดนปสสาวะ หนปนทอยในอวยวะตาง ๆ ในชองทอง รวมทงมองหาสงแปลกปลอม(foreign body)

ขอจ ำกดของ Plain film

bull ม Sensitivity และ Specificity ต า plain film ทปกตไมไดแปลวาไมมโรค เพราะความผดปกตบางอยางกไมสามารถพบในplain filmได เชนndash lesion ทเลก ๆndash lesion ทซอนอยใน blind area

ndash Blood clot

bull Plain film ทคณภาพไมดท าใหแปลผลผดพลาดไดงายbull ตองใชประสบการณในการอานคอนขางมาก

Chest X-ray

ทำทใชในกำรถำยภำพรงสทรวงอก

1Posteroanterior(PA)

ขนตอน ผปวยยนหนหนาเขาหาฟลมเงยคางขนเอาหลงมอแตะสะโพกงมไหลเขาหาฟลมเพอใหเงาชองกระดก

สะบกหลบจากเงาของปอด

bull ถาผปวยยนไมได ใหผปวยนงปลายเตยง ถายทาPA เอาฟลมไวดานหนากอดตลบฟลม

bull ถาผปวยนงลอเขนใหเอาฟลมไวหลงผปวย ชหมอนหนนใหล าตวอยในทาตรงถายทาAP

bull ถาผปวยอาการหนกไม สามารถลกได ใหถายทา AP supine แทน

Lateralใหผปวยเอาขางทสงสยมพยาธสภาพชดฟลม จดใหยนในทาตรงยกแขนขนเหนอศรษะ ล าแสงเขาดานตรงขามฟลม

ถาแพทยไมระบดานใดควรเอาดานซายชดฟลม เนองจากหวใจอยคอนมาทางดานซายเพอไมใหภาพขยายมากนก

ถาบรเวณทสงสยอยดานบนซงปกตจะมองไมเหน เนองจากมเงาของตนแขนและกระดกสะบกบงอย ใหผปวยงมไหลเอาแขนมาขางหนา หรอเอามอไปดานหลงเพอใหเหนรอยโรคไดชดเจน

Left anterior oblique

bull ใชเมอตองการถายภาพหวใจ เนองจากหวใจอยดานหนา จงตองถายในทา anterior oblique ใหผปวยยนเอาดานหนาขางซายชดฟลม ตะแคงตวประมาณ55องศาเพอหลบเงาหวใจแสงเขาขางหลงดานขวา

Right anterior oblique

bull ใหผปวยเอาดานหนาขางขวาชดฟลมเอยงตวประมาณ45องศาแสงเขาดานหลงขางซาย

Lateral decubitus

bull เปนทาทใชถายด air fluid level ในทานอนตะแคง โดยเอาขางทสงสยวามน าลงหรอดานทมลมขนดานบน

bull แพทยควรระบวาตองการภาพถายรงสทา Left หรอ Right

lateral decubitus เพอจะไดผลฟลมตามตองการ

Apical lordotic

เปนทาส าหรบดยอดปอดทานผปวยยนหางฟลมหลงเอนเทาชดฟลมแสงเอกซเรยจะเอยงผานใตระดบของประดกไหปลารา เพอใหเงาของกระดกนหลบไปจากเงาของยอดปอด ท าใหเหนยอดปอดไดชดเจน

หลกการแปลผลภาพรงส

1Identification

2Placing the film

3Techniques

-overunder exposure

-หายใจเขาเตมท กะบงลมขางขวาควรอยทระดบกระดซโครงชองท6ดานหนา(anterior right 6 rib) หรอชองท9ดานหลง (posterior

right 9-10 rib)

-ปลายกระดก clavicle จะหางจากขอบกระดก spinouts process of thoracic spine เปนระยะเทากนทง2ขาง

4อานตามหลกการ ABCDEF

Aairwaygtgtgt trachea

A midline structure that generally ranges in

length from 6-9cm diameter~15cm

-แยกเปนหลอดลมซายและขวาcarina(black arrow) ทระดบ -T4-5 vertebral body

Carinal angle ~ 75-85

degree

Blung parenchyma

upper lung zone เหนอ ICS2

middle lung zone ICS2-ICS4

lower lung zone อยใต middle lung zone

C Cardiac

bull Heart Cardiothoracic ratio normally lt05 in

adult

bull Aortic knob normally its caliber is ~ 3cm (

4cm in elder )

Ddiaphragm

อยทระดบICS 6ดานหนา อยระดบ ICS9-10ดานหลง

diaphragmขางขวาสงกวาดานซายประมาณครงชองของ Intercostal space

Left hemi diaphragm จะเหนเงาลมในกระเพาะ อยหางจากกระบงลม ~1cm แตไมเกน 2cm

E bone structureamp soft tissue shadows

Radiological sign

bull Air bronchogram

an air-filled bronchus against surrounding opacified alveoli It is indicative of an airspace process and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due to obstruction (as air is resorbed)

Found in

- Pneumonic consolidation

- Pulmonary edema

- Neonatal respiratory distress syndrome

ขอจ ำกดของ Plain film

bull ม Sensitivity และ Specificity ต า plain film ทปกตไมไดแปลวาไมมโรค เพราะความผดปกตบางอยางกไมสามารถพบในplain filmได เชนndash lesion ทเลก ๆndash lesion ทซอนอยใน blind area

ndash Blood clot

bull Plain film ทคณภาพไมดท าใหแปลผลผดพลาดไดงายbull ตองใชประสบการณในการอานคอนขางมาก

Chest X-ray

ทำทใชในกำรถำยภำพรงสทรวงอก

1Posteroanterior(PA)

ขนตอน ผปวยยนหนหนาเขาหาฟลมเงยคางขนเอาหลงมอแตะสะโพกงมไหลเขาหาฟลมเพอใหเงาชองกระดก

สะบกหลบจากเงาของปอด

bull ถาผปวยยนไมได ใหผปวยนงปลายเตยง ถายทาPA เอาฟลมไวดานหนากอดตลบฟลม

bull ถาผปวยนงลอเขนใหเอาฟลมไวหลงผปวย ชหมอนหนนใหล าตวอยในทาตรงถายทาAP

bull ถาผปวยอาการหนกไม สามารถลกได ใหถายทา AP supine แทน

Lateralใหผปวยเอาขางทสงสยมพยาธสภาพชดฟลม จดใหยนในทาตรงยกแขนขนเหนอศรษะ ล าแสงเขาดานตรงขามฟลม

ถาแพทยไมระบดานใดควรเอาดานซายชดฟลม เนองจากหวใจอยคอนมาทางดานซายเพอไมใหภาพขยายมากนก

ถาบรเวณทสงสยอยดานบนซงปกตจะมองไมเหน เนองจากมเงาของตนแขนและกระดกสะบกบงอย ใหผปวยงมไหลเอาแขนมาขางหนา หรอเอามอไปดานหลงเพอใหเหนรอยโรคไดชดเจน

Left anterior oblique

bull ใชเมอตองการถายภาพหวใจ เนองจากหวใจอยดานหนา จงตองถายในทา anterior oblique ใหผปวยยนเอาดานหนาขางซายชดฟลม ตะแคงตวประมาณ55องศาเพอหลบเงาหวใจแสงเขาขางหลงดานขวา

Right anterior oblique

bull ใหผปวยเอาดานหนาขางขวาชดฟลมเอยงตวประมาณ45องศาแสงเขาดานหลงขางซาย

Lateral decubitus

bull เปนทาทใชถายด air fluid level ในทานอนตะแคง โดยเอาขางทสงสยวามน าลงหรอดานทมลมขนดานบน

bull แพทยควรระบวาตองการภาพถายรงสทา Left หรอ Right

lateral decubitus เพอจะไดผลฟลมตามตองการ

Apical lordotic

เปนทาส าหรบดยอดปอดทานผปวยยนหางฟลมหลงเอนเทาชดฟลมแสงเอกซเรยจะเอยงผานใตระดบของประดกไหปลารา เพอใหเงาของกระดกนหลบไปจากเงาของยอดปอด ท าใหเหนยอดปอดไดชดเจน

หลกการแปลผลภาพรงส

1Identification

2Placing the film

3Techniques

-overunder exposure

-หายใจเขาเตมท กะบงลมขางขวาควรอยทระดบกระดซโครงชองท6ดานหนา(anterior right 6 rib) หรอชองท9ดานหลง (posterior

right 9-10 rib)

-ปลายกระดก clavicle จะหางจากขอบกระดก spinouts process of thoracic spine เปนระยะเทากนทง2ขาง

4อานตามหลกการ ABCDEF

Aairwaygtgtgt trachea

A midline structure that generally ranges in

length from 6-9cm diameter~15cm

-แยกเปนหลอดลมซายและขวาcarina(black arrow) ทระดบ -T4-5 vertebral body

Carinal angle ~ 75-85

degree

Blung parenchyma

upper lung zone เหนอ ICS2

middle lung zone ICS2-ICS4

lower lung zone อยใต middle lung zone

C Cardiac

bull Heart Cardiothoracic ratio normally lt05 in

adult

bull Aortic knob normally its caliber is ~ 3cm (

4cm in elder )

Ddiaphragm

อยทระดบICS 6ดานหนา อยระดบ ICS9-10ดานหลง

diaphragmขางขวาสงกวาดานซายประมาณครงชองของ Intercostal space

Left hemi diaphragm จะเหนเงาลมในกระเพาะ อยหางจากกระบงลม ~1cm แตไมเกน 2cm

E bone structureamp soft tissue shadows

Radiological sign

bull Air bronchogram

an air-filled bronchus against surrounding opacified alveoli It is indicative of an airspace process and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due to obstruction (as air is resorbed)

Found in

- Pneumonic consolidation

- Pulmonary edema

- Neonatal respiratory distress syndrome

Chest X-ray

ทำทใชในกำรถำยภำพรงสทรวงอก

1Posteroanterior(PA)

ขนตอน ผปวยยนหนหนาเขาหาฟลมเงยคางขนเอาหลงมอแตะสะโพกงมไหลเขาหาฟลมเพอใหเงาชองกระดก

สะบกหลบจากเงาของปอด

bull ถาผปวยยนไมได ใหผปวยนงปลายเตยง ถายทาPA เอาฟลมไวดานหนากอดตลบฟลม

bull ถาผปวยนงลอเขนใหเอาฟลมไวหลงผปวย ชหมอนหนนใหล าตวอยในทาตรงถายทาAP

bull ถาผปวยอาการหนกไม สามารถลกได ใหถายทา AP supine แทน

Lateralใหผปวยเอาขางทสงสยมพยาธสภาพชดฟลม จดใหยนในทาตรงยกแขนขนเหนอศรษะ ล าแสงเขาดานตรงขามฟลม

ถาแพทยไมระบดานใดควรเอาดานซายชดฟลม เนองจากหวใจอยคอนมาทางดานซายเพอไมใหภาพขยายมากนก

ถาบรเวณทสงสยอยดานบนซงปกตจะมองไมเหน เนองจากมเงาของตนแขนและกระดกสะบกบงอย ใหผปวยงมไหลเอาแขนมาขางหนา หรอเอามอไปดานหลงเพอใหเหนรอยโรคไดชดเจน

Left anterior oblique

bull ใชเมอตองการถายภาพหวใจ เนองจากหวใจอยดานหนา จงตองถายในทา anterior oblique ใหผปวยยนเอาดานหนาขางซายชดฟลม ตะแคงตวประมาณ55องศาเพอหลบเงาหวใจแสงเขาขางหลงดานขวา

Right anterior oblique

bull ใหผปวยเอาดานหนาขางขวาชดฟลมเอยงตวประมาณ45องศาแสงเขาดานหลงขางซาย

Lateral decubitus

bull เปนทาทใชถายด air fluid level ในทานอนตะแคง โดยเอาขางทสงสยวามน าลงหรอดานทมลมขนดานบน

bull แพทยควรระบวาตองการภาพถายรงสทา Left หรอ Right

lateral decubitus เพอจะไดผลฟลมตามตองการ

Apical lordotic

เปนทาส าหรบดยอดปอดทานผปวยยนหางฟลมหลงเอนเทาชดฟลมแสงเอกซเรยจะเอยงผานใตระดบของประดกไหปลารา เพอใหเงาของกระดกนหลบไปจากเงาของยอดปอด ท าใหเหนยอดปอดไดชดเจน

หลกการแปลผลภาพรงส

1Identification

2Placing the film

3Techniques

-overunder exposure

-หายใจเขาเตมท กะบงลมขางขวาควรอยทระดบกระดซโครงชองท6ดานหนา(anterior right 6 rib) หรอชองท9ดานหลง (posterior

right 9-10 rib)

-ปลายกระดก clavicle จะหางจากขอบกระดก spinouts process of thoracic spine เปนระยะเทากนทง2ขาง

4อานตามหลกการ ABCDEF

Aairwaygtgtgt trachea

A midline structure that generally ranges in

length from 6-9cm diameter~15cm

-แยกเปนหลอดลมซายและขวาcarina(black arrow) ทระดบ -T4-5 vertebral body

Carinal angle ~ 75-85

degree

Blung parenchyma

upper lung zone เหนอ ICS2

middle lung zone ICS2-ICS4

lower lung zone อยใต middle lung zone

C Cardiac

bull Heart Cardiothoracic ratio normally lt05 in

adult

bull Aortic knob normally its caliber is ~ 3cm (

4cm in elder )

Ddiaphragm

อยทระดบICS 6ดานหนา อยระดบ ICS9-10ดานหลง

diaphragmขางขวาสงกวาดานซายประมาณครงชองของ Intercostal space

Left hemi diaphragm จะเหนเงาลมในกระเพาะ อยหางจากกระบงลม ~1cm แตไมเกน 2cm

E bone structureamp soft tissue shadows

Radiological sign

bull Air bronchogram

an air-filled bronchus against surrounding opacified alveoli It is indicative of an airspace process and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due to obstruction (as air is resorbed)

Found in

- Pneumonic consolidation

- Pulmonary edema

- Neonatal respiratory distress syndrome

ทำทใชในกำรถำยภำพรงสทรวงอก

1Posteroanterior(PA)

ขนตอน ผปวยยนหนหนาเขาหาฟลมเงยคางขนเอาหลงมอแตะสะโพกงมไหลเขาหาฟลมเพอใหเงาชองกระดก

สะบกหลบจากเงาของปอด

bull ถาผปวยยนไมได ใหผปวยนงปลายเตยง ถายทาPA เอาฟลมไวดานหนากอดตลบฟลม

bull ถาผปวยนงลอเขนใหเอาฟลมไวหลงผปวย ชหมอนหนนใหล าตวอยในทาตรงถายทาAP

bull ถาผปวยอาการหนกไม สามารถลกได ใหถายทา AP supine แทน

Lateralใหผปวยเอาขางทสงสยมพยาธสภาพชดฟลม จดใหยนในทาตรงยกแขนขนเหนอศรษะ ล าแสงเขาดานตรงขามฟลม

ถาแพทยไมระบดานใดควรเอาดานซายชดฟลม เนองจากหวใจอยคอนมาทางดานซายเพอไมใหภาพขยายมากนก

ถาบรเวณทสงสยอยดานบนซงปกตจะมองไมเหน เนองจากมเงาของตนแขนและกระดกสะบกบงอย ใหผปวยงมไหลเอาแขนมาขางหนา หรอเอามอไปดานหลงเพอใหเหนรอยโรคไดชดเจน

Left anterior oblique

bull ใชเมอตองการถายภาพหวใจ เนองจากหวใจอยดานหนา จงตองถายในทา anterior oblique ใหผปวยยนเอาดานหนาขางซายชดฟลม ตะแคงตวประมาณ55องศาเพอหลบเงาหวใจแสงเขาขางหลงดานขวา

Right anterior oblique

bull ใหผปวยเอาดานหนาขางขวาชดฟลมเอยงตวประมาณ45องศาแสงเขาดานหลงขางซาย

Lateral decubitus

bull เปนทาทใชถายด air fluid level ในทานอนตะแคง โดยเอาขางทสงสยวามน าลงหรอดานทมลมขนดานบน

bull แพทยควรระบวาตองการภาพถายรงสทา Left หรอ Right

lateral decubitus เพอจะไดผลฟลมตามตองการ

Apical lordotic

เปนทาส าหรบดยอดปอดทานผปวยยนหางฟลมหลงเอนเทาชดฟลมแสงเอกซเรยจะเอยงผานใตระดบของประดกไหปลารา เพอใหเงาของกระดกนหลบไปจากเงาของยอดปอด ท าใหเหนยอดปอดไดชดเจน

หลกการแปลผลภาพรงส

1Identification

2Placing the film

3Techniques

-overunder exposure

-หายใจเขาเตมท กะบงลมขางขวาควรอยทระดบกระดซโครงชองท6ดานหนา(anterior right 6 rib) หรอชองท9ดานหลง (posterior

right 9-10 rib)

-ปลายกระดก clavicle จะหางจากขอบกระดก spinouts process of thoracic spine เปนระยะเทากนทง2ขาง

4อานตามหลกการ ABCDEF

Aairwaygtgtgt trachea

A midline structure that generally ranges in

length from 6-9cm diameter~15cm

-แยกเปนหลอดลมซายและขวาcarina(black arrow) ทระดบ -T4-5 vertebral body

Carinal angle ~ 75-85

degree

Blung parenchyma

upper lung zone เหนอ ICS2

middle lung zone ICS2-ICS4

lower lung zone อยใต middle lung zone

C Cardiac

bull Heart Cardiothoracic ratio normally lt05 in

adult

bull Aortic knob normally its caliber is ~ 3cm (

4cm in elder )

Ddiaphragm

อยทระดบICS 6ดานหนา อยระดบ ICS9-10ดานหลง

diaphragmขางขวาสงกวาดานซายประมาณครงชองของ Intercostal space

Left hemi diaphragm จะเหนเงาลมในกระเพาะ อยหางจากกระบงลม ~1cm แตไมเกน 2cm

E bone structureamp soft tissue shadows

Radiological sign

bull Air bronchogram

an air-filled bronchus against surrounding opacified alveoli It is indicative of an airspace process and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due to obstruction (as air is resorbed)

Found in

- Pneumonic consolidation

- Pulmonary edema

- Neonatal respiratory distress syndrome

bull ถาผปวยยนไมได ใหผปวยนงปลายเตยง ถายทาPA เอาฟลมไวดานหนากอดตลบฟลม

bull ถาผปวยนงลอเขนใหเอาฟลมไวหลงผปวย ชหมอนหนนใหล าตวอยในทาตรงถายทาAP

bull ถาผปวยอาการหนกไม สามารถลกได ใหถายทา AP supine แทน

Lateralใหผปวยเอาขางทสงสยมพยาธสภาพชดฟลม จดใหยนในทาตรงยกแขนขนเหนอศรษะ ล าแสงเขาดานตรงขามฟลม

ถาแพทยไมระบดานใดควรเอาดานซายชดฟลม เนองจากหวใจอยคอนมาทางดานซายเพอไมใหภาพขยายมากนก

ถาบรเวณทสงสยอยดานบนซงปกตจะมองไมเหน เนองจากมเงาของตนแขนและกระดกสะบกบงอย ใหผปวยงมไหลเอาแขนมาขางหนา หรอเอามอไปดานหลงเพอใหเหนรอยโรคไดชดเจน

Left anterior oblique

bull ใชเมอตองการถายภาพหวใจ เนองจากหวใจอยดานหนา จงตองถายในทา anterior oblique ใหผปวยยนเอาดานหนาขางซายชดฟลม ตะแคงตวประมาณ55องศาเพอหลบเงาหวใจแสงเขาขางหลงดานขวา

Right anterior oblique

bull ใหผปวยเอาดานหนาขางขวาชดฟลมเอยงตวประมาณ45องศาแสงเขาดานหลงขางซาย

Lateral decubitus

bull เปนทาทใชถายด air fluid level ในทานอนตะแคง โดยเอาขางทสงสยวามน าลงหรอดานทมลมขนดานบน

bull แพทยควรระบวาตองการภาพถายรงสทา Left หรอ Right

lateral decubitus เพอจะไดผลฟลมตามตองการ

Apical lordotic

เปนทาส าหรบดยอดปอดทานผปวยยนหางฟลมหลงเอนเทาชดฟลมแสงเอกซเรยจะเอยงผานใตระดบของประดกไหปลารา เพอใหเงาของกระดกนหลบไปจากเงาของยอดปอด ท าใหเหนยอดปอดไดชดเจน

หลกการแปลผลภาพรงส

1Identification

2Placing the film

3Techniques

-overunder exposure

-หายใจเขาเตมท กะบงลมขางขวาควรอยทระดบกระดซโครงชองท6ดานหนา(anterior right 6 rib) หรอชองท9ดานหลง (posterior

right 9-10 rib)

-ปลายกระดก clavicle จะหางจากขอบกระดก spinouts process of thoracic spine เปนระยะเทากนทง2ขาง

4อานตามหลกการ ABCDEF

Aairwaygtgtgt trachea

A midline structure that generally ranges in

length from 6-9cm diameter~15cm

-แยกเปนหลอดลมซายและขวาcarina(black arrow) ทระดบ -T4-5 vertebral body

Carinal angle ~ 75-85

degree

Blung parenchyma

upper lung zone เหนอ ICS2

middle lung zone ICS2-ICS4

lower lung zone อยใต middle lung zone

C Cardiac

bull Heart Cardiothoracic ratio normally lt05 in

adult

bull Aortic knob normally its caliber is ~ 3cm (

4cm in elder )

Ddiaphragm

อยทระดบICS 6ดานหนา อยระดบ ICS9-10ดานหลง

diaphragmขางขวาสงกวาดานซายประมาณครงชองของ Intercostal space

Left hemi diaphragm จะเหนเงาลมในกระเพาะ อยหางจากกระบงลม ~1cm แตไมเกน 2cm

E bone structureamp soft tissue shadows

Radiological sign

bull Air bronchogram

an air-filled bronchus against surrounding opacified alveoli It is indicative of an airspace process and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due to obstruction (as air is resorbed)

Found in

- Pneumonic consolidation

- Pulmonary edema

- Neonatal respiratory distress syndrome

Lateralใหผปวยเอาขางทสงสยมพยาธสภาพชดฟลม จดใหยนในทาตรงยกแขนขนเหนอศรษะ ล าแสงเขาดานตรงขามฟลม

ถาแพทยไมระบดานใดควรเอาดานซายชดฟลม เนองจากหวใจอยคอนมาทางดานซายเพอไมใหภาพขยายมากนก

ถาบรเวณทสงสยอยดานบนซงปกตจะมองไมเหน เนองจากมเงาของตนแขนและกระดกสะบกบงอย ใหผปวยงมไหลเอาแขนมาขางหนา หรอเอามอไปดานหลงเพอใหเหนรอยโรคไดชดเจน

Left anterior oblique

bull ใชเมอตองการถายภาพหวใจ เนองจากหวใจอยดานหนา จงตองถายในทา anterior oblique ใหผปวยยนเอาดานหนาขางซายชดฟลม ตะแคงตวประมาณ55องศาเพอหลบเงาหวใจแสงเขาขางหลงดานขวา

Right anterior oblique

bull ใหผปวยเอาดานหนาขางขวาชดฟลมเอยงตวประมาณ45องศาแสงเขาดานหลงขางซาย

Lateral decubitus

bull เปนทาทใชถายด air fluid level ในทานอนตะแคง โดยเอาขางทสงสยวามน าลงหรอดานทมลมขนดานบน

bull แพทยควรระบวาตองการภาพถายรงสทา Left หรอ Right

lateral decubitus เพอจะไดผลฟลมตามตองการ

Apical lordotic

เปนทาส าหรบดยอดปอดทานผปวยยนหางฟลมหลงเอนเทาชดฟลมแสงเอกซเรยจะเอยงผานใตระดบของประดกไหปลารา เพอใหเงาของกระดกนหลบไปจากเงาของยอดปอด ท าใหเหนยอดปอดไดชดเจน

หลกการแปลผลภาพรงส

1Identification

2Placing the film

3Techniques

-overunder exposure

-หายใจเขาเตมท กะบงลมขางขวาควรอยทระดบกระดซโครงชองท6ดานหนา(anterior right 6 rib) หรอชองท9ดานหลง (posterior

right 9-10 rib)

-ปลายกระดก clavicle จะหางจากขอบกระดก spinouts process of thoracic spine เปนระยะเทากนทง2ขาง

4อานตามหลกการ ABCDEF

Aairwaygtgtgt trachea

A midline structure that generally ranges in

length from 6-9cm diameter~15cm

-แยกเปนหลอดลมซายและขวาcarina(black arrow) ทระดบ -T4-5 vertebral body

Carinal angle ~ 75-85

degree

Blung parenchyma

upper lung zone เหนอ ICS2

middle lung zone ICS2-ICS4

lower lung zone อยใต middle lung zone

C Cardiac

bull Heart Cardiothoracic ratio normally lt05 in

adult

bull Aortic knob normally its caliber is ~ 3cm (

4cm in elder )

Ddiaphragm

อยทระดบICS 6ดานหนา อยระดบ ICS9-10ดานหลง

diaphragmขางขวาสงกวาดานซายประมาณครงชองของ Intercostal space

Left hemi diaphragm จะเหนเงาลมในกระเพาะ อยหางจากกระบงลม ~1cm แตไมเกน 2cm

E bone structureamp soft tissue shadows

Radiological sign

bull Air bronchogram

an air-filled bronchus against surrounding opacified alveoli It is indicative of an airspace process and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due to obstruction (as air is resorbed)

Found in

- Pneumonic consolidation

- Pulmonary edema

- Neonatal respiratory distress syndrome

Left anterior oblique

bull ใชเมอตองการถายภาพหวใจ เนองจากหวใจอยดานหนา จงตองถายในทา anterior oblique ใหผปวยยนเอาดานหนาขางซายชดฟลม ตะแคงตวประมาณ55องศาเพอหลบเงาหวใจแสงเขาขางหลงดานขวา

Right anterior oblique

bull ใหผปวยเอาดานหนาขางขวาชดฟลมเอยงตวประมาณ45องศาแสงเขาดานหลงขางซาย

Lateral decubitus

bull เปนทาทใชถายด air fluid level ในทานอนตะแคง โดยเอาขางทสงสยวามน าลงหรอดานทมลมขนดานบน

bull แพทยควรระบวาตองการภาพถายรงสทา Left หรอ Right

lateral decubitus เพอจะไดผลฟลมตามตองการ

Apical lordotic

เปนทาส าหรบดยอดปอดทานผปวยยนหางฟลมหลงเอนเทาชดฟลมแสงเอกซเรยจะเอยงผานใตระดบของประดกไหปลารา เพอใหเงาของกระดกนหลบไปจากเงาของยอดปอด ท าใหเหนยอดปอดไดชดเจน

หลกการแปลผลภาพรงส

1Identification

2Placing the film

3Techniques

-overunder exposure

-หายใจเขาเตมท กะบงลมขางขวาควรอยทระดบกระดซโครงชองท6ดานหนา(anterior right 6 rib) หรอชองท9ดานหลง (posterior

right 9-10 rib)

-ปลายกระดก clavicle จะหางจากขอบกระดก spinouts process of thoracic spine เปนระยะเทากนทง2ขาง

4อานตามหลกการ ABCDEF

Aairwaygtgtgt trachea

A midline structure that generally ranges in

length from 6-9cm diameter~15cm

-แยกเปนหลอดลมซายและขวาcarina(black arrow) ทระดบ -T4-5 vertebral body

Carinal angle ~ 75-85

degree

Blung parenchyma

upper lung zone เหนอ ICS2

middle lung zone ICS2-ICS4

lower lung zone อยใต middle lung zone

C Cardiac

bull Heart Cardiothoracic ratio normally lt05 in

adult

bull Aortic knob normally its caliber is ~ 3cm (

4cm in elder )

Ddiaphragm

อยทระดบICS 6ดานหนา อยระดบ ICS9-10ดานหลง

diaphragmขางขวาสงกวาดานซายประมาณครงชองของ Intercostal space

Left hemi diaphragm จะเหนเงาลมในกระเพาะ อยหางจากกระบงลม ~1cm แตไมเกน 2cm

E bone structureamp soft tissue shadows

Radiological sign

bull Air bronchogram

an air-filled bronchus against surrounding opacified alveoli It is indicative of an airspace process and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due to obstruction (as air is resorbed)

Found in

- Pneumonic consolidation

- Pulmonary edema

- Neonatal respiratory distress syndrome

Right anterior oblique

bull ใหผปวยเอาดานหนาขางขวาชดฟลมเอยงตวประมาณ45องศาแสงเขาดานหลงขางซาย

Lateral decubitus

bull เปนทาทใชถายด air fluid level ในทานอนตะแคง โดยเอาขางทสงสยวามน าลงหรอดานทมลมขนดานบน

bull แพทยควรระบวาตองการภาพถายรงสทา Left หรอ Right

lateral decubitus เพอจะไดผลฟลมตามตองการ

Apical lordotic

เปนทาส าหรบดยอดปอดทานผปวยยนหางฟลมหลงเอนเทาชดฟลมแสงเอกซเรยจะเอยงผานใตระดบของประดกไหปลารา เพอใหเงาของกระดกนหลบไปจากเงาของยอดปอด ท าใหเหนยอดปอดไดชดเจน

หลกการแปลผลภาพรงส

1Identification

2Placing the film

3Techniques

-overunder exposure

-หายใจเขาเตมท กะบงลมขางขวาควรอยทระดบกระดซโครงชองท6ดานหนา(anterior right 6 rib) หรอชองท9ดานหลง (posterior

right 9-10 rib)

-ปลายกระดก clavicle จะหางจากขอบกระดก spinouts process of thoracic spine เปนระยะเทากนทง2ขาง

4อานตามหลกการ ABCDEF

Aairwaygtgtgt trachea

A midline structure that generally ranges in

length from 6-9cm diameter~15cm

-แยกเปนหลอดลมซายและขวาcarina(black arrow) ทระดบ -T4-5 vertebral body

Carinal angle ~ 75-85

degree

Blung parenchyma

upper lung zone เหนอ ICS2

middle lung zone ICS2-ICS4

lower lung zone อยใต middle lung zone

C Cardiac

bull Heart Cardiothoracic ratio normally lt05 in

adult

bull Aortic knob normally its caliber is ~ 3cm (

4cm in elder )

Ddiaphragm

อยทระดบICS 6ดานหนา อยระดบ ICS9-10ดานหลง

diaphragmขางขวาสงกวาดานซายประมาณครงชองของ Intercostal space

Left hemi diaphragm จะเหนเงาลมในกระเพาะ อยหางจากกระบงลม ~1cm แตไมเกน 2cm

E bone structureamp soft tissue shadows

Radiological sign

bull Air bronchogram

an air-filled bronchus against surrounding opacified alveoli It is indicative of an airspace process and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due to obstruction (as air is resorbed)

Found in

- Pneumonic consolidation

- Pulmonary edema

- Neonatal respiratory distress syndrome

Lateral decubitus

bull เปนทาทใชถายด air fluid level ในทานอนตะแคง โดยเอาขางทสงสยวามน าลงหรอดานทมลมขนดานบน

bull แพทยควรระบวาตองการภาพถายรงสทา Left หรอ Right

lateral decubitus เพอจะไดผลฟลมตามตองการ

Apical lordotic

เปนทาส าหรบดยอดปอดทานผปวยยนหางฟลมหลงเอนเทาชดฟลมแสงเอกซเรยจะเอยงผานใตระดบของประดกไหปลารา เพอใหเงาของกระดกนหลบไปจากเงาของยอดปอด ท าใหเหนยอดปอดไดชดเจน

หลกการแปลผลภาพรงส

1Identification

2Placing the film

3Techniques

-overunder exposure

-หายใจเขาเตมท กะบงลมขางขวาควรอยทระดบกระดซโครงชองท6ดานหนา(anterior right 6 rib) หรอชองท9ดานหลง (posterior

right 9-10 rib)

-ปลายกระดก clavicle จะหางจากขอบกระดก spinouts process of thoracic spine เปนระยะเทากนทง2ขาง

4อานตามหลกการ ABCDEF

Aairwaygtgtgt trachea

A midline structure that generally ranges in

length from 6-9cm diameter~15cm

-แยกเปนหลอดลมซายและขวาcarina(black arrow) ทระดบ -T4-5 vertebral body

Carinal angle ~ 75-85

degree

Blung parenchyma

upper lung zone เหนอ ICS2

middle lung zone ICS2-ICS4

lower lung zone อยใต middle lung zone

C Cardiac

bull Heart Cardiothoracic ratio normally lt05 in

adult

bull Aortic knob normally its caliber is ~ 3cm (

4cm in elder )

Ddiaphragm

อยทระดบICS 6ดานหนา อยระดบ ICS9-10ดานหลง

diaphragmขางขวาสงกวาดานซายประมาณครงชองของ Intercostal space

Left hemi diaphragm จะเหนเงาลมในกระเพาะ อยหางจากกระบงลม ~1cm แตไมเกน 2cm

E bone structureamp soft tissue shadows

Radiological sign

bull Air bronchogram

an air-filled bronchus against surrounding opacified alveoli It is indicative of an airspace process and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due to obstruction (as air is resorbed)

Found in

- Pneumonic consolidation

- Pulmonary edema

- Neonatal respiratory distress syndrome

Apical lordotic

เปนทาส าหรบดยอดปอดทานผปวยยนหางฟลมหลงเอนเทาชดฟลมแสงเอกซเรยจะเอยงผานใตระดบของประดกไหปลารา เพอใหเงาของกระดกนหลบไปจากเงาของยอดปอด ท าใหเหนยอดปอดไดชดเจน

หลกการแปลผลภาพรงส

1Identification

2Placing the film

3Techniques

-overunder exposure

-หายใจเขาเตมท กะบงลมขางขวาควรอยทระดบกระดซโครงชองท6ดานหนา(anterior right 6 rib) หรอชองท9ดานหลง (posterior

right 9-10 rib)

-ปลายกระดก clavicle จะหางจากขอบกระดก spinouts process of thoracic spine เปนระยะเทากนทง2ขาง

4อานตามหลกการ ABCDEF

Aairwaygtgtgt trachea

A midline structure that generally ranges in

length from 6-9cm diameter~15cm

-แยกเปนหลอดลมซายและขวาcarina(black arrow) ทระดบ -T4-5 vertebral body

Carinal angle ~ 75-85

degree

Blung parenchyma

upper lung zone เหนอ ICS2

middle lung zone ICS2-ICS4

lower lung zone อยใต middle lung zone

C Cardiac

bull Heart Cardiothoracic ratio normally lt05 in

adult

bull Aortic knob normally its caliber is ~ 3cm (

4cm in elder )

Ddiaphragm

อยทระดบICS 6ดานหนา อยระดบ ICS9-10ดานหลง

diaphragmขางขวาสงกวาดานซายประมาณครงชองของ Intercostal space

Left hemi diaphragm จะเหนเงาลมในกระเพาะ อยหางจากกระบงลม ~1cm แตไมเกน 2cm

E bone structureamp soft tissue shadows

Radiological sign

bull Air bronchogram

an air-filled bronchus against surrounding opacified alveoli It is indicative of an airspace process and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due to obstruction (as air is resorbed)

Found in

- Pneumonic consolidation

- Pulmonary edema

- Neonatal respiratory distress syndrome

หลกการแปลผลภาพรงส

1Identification

2Placing the film

3Techniques

-overunder exposure

-หายใจเขาเตมท กะบงลมขางขวาควรอยทระดบกระดซโครงชองท6ดานหนา(anterior right 6 rib) หรอชองท9ดานหลง (posterior

right 9-10 rib)

-ปลายกระดก clavicle จะหางจากขอบกระดก spinouts process of thoracic spine เปนระยะเทากนทง2ขาง

4อานตามหลกการ ABCDEF

Aairwaygtgtgt trachea

A midline structure that generally ranges in

length from 6-9cm diameter~15cm

-แยกเปนหลอดลมซายและขวาcarina(black arrow) ทระดบ -T4-5 vertebral body

Carinal angle ~ 75-85

degree

Blung parenchyma

upper lung zone เหนอ ICS2

middle lung zone ICS2-ICS4

lower lung zone อยใต middle lung zone

C Cardiac

bull Heart Cardiothoracic ratio normally lt05 in

adult

bull Aortic knob normally its caliber is ~ 3cm (

4cm in elder )

Ddiaphragm

อยทระดบICS 6ดานหนา อยระดบ ICS9-10ดานหลง

diaphragmขางขวาสงกวาดานซายประมาณครงชองของ Intercostal space

Left hemi diaphragm จะเหนเงาลมในกระเพาะ อยหางจากกระบงลม ~1cm แตไมเกน 2cm

E bone structureamp soft tissue shadows

Radiological sign

bull Air bronchogram

an air-filled bronchus against surrounding opacified alveoli It is indicative of an airspace process and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due to obstruction (as air is resorbed)

Found in

- Pneumonic consolidation

- Pulmonary edema

- Neonatal respiratory distress syndrome

4อานตามหลกการ ABCDEF

Aairwaygtgtgt trachea

A midline structure that generally ranges in

length from 6-9cm diameter~15cm

-แยกเปนหลอดลมซายและขวาcarina(black arrow) ทระดบ -T4-5 vertebral body

Carinal angle ~ 75-85

degree

Blung parenchyma

upper lung zone เหนอ ICS2

middle lung zone ICS2-ICS4

lower lung zone อยใต middle lung zone

C Cardiac

bull Heart Cardiothoracic ratio normally lt05 in

adult

bull Aortic knob normally its caliber is ~ 3cm (

4cm in elder )

Ddiaphragm

อยทระดบICS 6ดานหนา อยระดบ ICS9-10ดานหลง

diaphragmขางขวาสงกวาดานซายประมาณครงชองของ Intercostal space

Left hemi diaphragm จะเหนเงาลมในกระเพาะ อยหางจากกระบงลม ~1cm แตไมเกน 2cm

E bone structureamp soft tissue shadows

Radiological sign

bull Air bronchogram

an air-filled bronchus against surrounding opacified alveoli It is indicative of an airspace process and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due to obstruction (as air is resorbed)

Found in

- Pneumonic consolidation

- Pulmonary edema

- Neonatal respiratory distress syndrome

Blung parenchyma

upper lung zone เหนอ ICS2

middle lung zone ICS2-ICS4

lower lung zone อยใต middle lung zone

C Cardiac

bull Heart Cardiothoracic ratio normally lt05 in

adult

bull Aortic knob normally its caliber is ~ 3cm (

4cm in elder )

Ddiaphragm

อยทระดบICS 6ดานหนา อยระดบ ICS9-10ดานหลง

diaphragmขางขวาสงกวาดานซายประมาณครงชองของ Intercostal space

Left hemi diaphragm จะเหนเงาลมในกระเพาะ อยหางจากกระบงลม ~1cm แตไมเกน 2cm

E bone structureamp soft tissue shadows

Radiological sign

bull Air bronchogram

an air-filled bronchus against surrounding opacified alveoli It is indicative of an airspace process and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due to obstruction (as air is resorbed)

Found in

- Pneumonic consolidation

- Pulmonary edema

- Neonatal respiratory distress syndrome

C Cardiac

bull Heart Cardiothoracic ratio normally lt05 in

adult

bull Aortic knob normally its caliber is ~ 3cm (

4cm in elder )

Ddiaphragm

อยทระดบICS 6ดานหนา อยระดบ ICS9-10ดานหลง

diaphragmขางขวาสงกวาดานซายประมาณครงชองของ Intercostal space

Left hemi diaphragm จะเหนเงาลมในกระเพาะ อยหางจากกระบงลม ~1cm แตไมเกน 2cm

E bone structureamp soft tissue shadows

Radiological sign

bull Air bronchogram

an air-filled bronchus against surrounding opacified alveoli It is indicative of an airspace process and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due to obstruction (as air is resorbed)

Found in

- Pneumonic consolidation

- Pulmonary edema

- Neonatal respiratory distress syndrome

Ddiaphragm

อยทระดบICS 6ดานหนา อยระดบ ICS9-10ดานหลง

diaphragmขางขวาสงกวาดานซายประมาณครงชองของ Intercostal space

Left hemi diaphragm จะเหนเงาลมในกระเพาะ อยหางจากกระบงลม ~1cm แตไมเกน 2cm

E bone structureamp soft tissue shadows

Radiological sign

bull Air bronchogram

an air-filled bronchus against surrounding opacified alveoli It is indicative of an airspace process and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due to obstruction (as air is resorbed)

Found in

- Pneumonic consolidation

- Pulmonary edema

- Neonatal respiratory distress syndrome

Radiological sign

bull Air bronchogram

an air-filled bronchus against surrounding opacified alveoli It is indicative of an airspace process and will not be seen when a bronchus is filled with fluid or when the opacification of the alveoli is due to obstruction (as air is resorbed)

Found in

- Pneumonic consolidation

- Pulmonary edema

- Neonatal respiratory distress syndrome

bull Silhouette sign

Two substances of the same density cannot be

differentiated from each other on X-ray This

phenomenon the loss of the normal

radiographic silhouette (contour)is called the Silhouette sign

Silhouettestructure Contact with lung

Upper right heartasc Ao Ant Segment RUL

Right heart border RML(medial)

Upper left heart border Ant Segment LUL

Left heart border Lingula(Ant)

Aortic knob Apical portion LUL

Hemi diaphragm Lower lobe

bull Cervicothoracic sign

The location of a lesion at the inlet of the thoracic cavity In this anatomical space the posterior portions of the lung apices are located more superiorly than the anterior portions For this reason a lesion clearly visible above the clavicles on the frontal view must lie posteriorly and be entirely within the thorax If the cranial border of the lesion is obscured at or below the level of the clavicles it is located at the anterior mediastinum The borders are not clearly delineated because the lesion is far from the air filled lung and there are cervical soft tissues at this level

Radiological lung disease

bull Predominately airspace disease

1 Acinar shadow

A round or ovoid poorly defined pulmonary

opacity 4-8 mm in diameter presumed to

representa pulmonary acinus rendered opaque

by consolidation This term is usually used in the presence of many such opacities

2 Consolidation

The process by which air in the lung is

replaced by the products of disease rendering the

lung solid (as in the case of pneumonia)

Radiographically consolidation is seen as

relatively homogeneous

opacity in the lung with little or no volume loss

effacement of pulmonary blood vessels and

sometimes the presence of the air bronchogram

3 Air bronchogram

4 Butterfly or Batrsquos wings distribution

Ex

- Pulmonary edema

- Pneumonia

- Pneumocystis infection

- Intraalveolar hemorrhage

bull Predominately interstitial disease

1 Septal pattern

ex Hydrostatic pulmonary edema malignancy

- Kerley A line

- Kerley B line

2 Reticular pattern

ex Asbestosis Idiopathic pulmonary fibrosis

3 Nodular pattern

ex Silicosis Miliary fungal infection

4 Reticulonodular pattern

ex Langerhansrsquo cell histiocytosis Lymphangitic

carcinomatosis

5 Ground glass pattern

ex PCP pulmonary hemorrhage

Diffuse pulmonary hemorrhage

Chest radiograph shows ground-glass

opacities involving mainly the lower

lung zones The patient was an 18-

year-old woman with diffuse

pulmonary hemorrhage due to vasculitis

bull Parenchymal atelectasis

- Direct sign Displacement of

interlobar fissure (white arrow)

- Indirect sign

ndash Displacement of hilar vessels

ndash Elevation of diaphragm

(black arrow)

ndash Mediastinal shift

ndash Compensatory emphysema

ndash Approximation of the ribs

ndash Tracheal shift (arrowhead)

bull Pneumonia

1 Lobar pneumonia

- Consolidation

- Air bronchogram

- S pneumoniae K pneumonia

2 Round pneumonia

- Soft tissue mass

- Air bronchogram

- Spneumoniae H influenzae

3 Lobular pneumonia

- Multifocal patchy opacities

- Peribronchial infiltration(Thickening of

peribronchial wall)

- Volume loss

- S aureus gram negative bacilli

Mycobacterium tuberculosis Mycoplasma

pneumonia

4Interstitial pneumonia

- Ground glass infiltrationndash PCP

- Peribronchial thickening and perihilar

infiltrationndash Viral pneumonia Mycoplasma

pneumonia

- Reticulonodular shadowing of lunglocalized or

wide spreadmdashPulmonary tuberculosis

- Miliary patternmdashMiliary tuberculosis

bull Pulmonary edema

1 Cardiogenic pulmonary edema

- Interstitial pattern

septal line peribronchial

thickeningsubpleural

pulmonary edema

- Alveolar edema

air space shadow

bat-wing

- Cardiomegaly

2 Non cardiogenic pulmonary edema

- Patchy ill-defined density

- Normal heart

- Normal upper

lobe blood distribution

- No pleural effusion

bull Lung mass

1 Solitary pulmonary nodule

- less than 2 cm

ex Malignant neoplasm Infectious granuloma(TB

Fungus) Benign tumor(hamartoma)

Solitary pulmonary nodule

Cavitating nodule secondary to an abscess

2 Multiple nodule

- small sized nodule(2-5 mm)

ex Pulmonary tuberculosis

- medium sized nodule(5-20 mm)

ex Metastatic lesion

- large sized nodule(gt20 mm) ex Lung metastatic

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Silhouettestructure Contact with lung

Upper right heartasc Ao Ant Segment RUL

Right heart border RML(medial)

Upper left heart border Ant Segment LUL

Left heart border Lingula(Ant)

Aortic knob Apical portion LUL

Hemi diaphragm Lower lobe

bull Cervicothoracic sign

The location of a lesion at the inlet of the thoracic cavity In this anatomical space the posterior portions of the lung apices are located more superiorly than the anterior portions For this reason a lesion clearly visible above the clavicles on the frontal view must lie posteriorly and be entirely within the thorax If the cranial border of the lesion is obscured at or below the level of the clavicles it is located at the anterior mediastinum The borders are not clearly delineated because the lesion is far from the air filled lung and there are cervical soft tissues at this level

Radiological lung disease

bull Predominately airspace disease

1 Acinar shadow

A round or ovoid poorly defined pulmonary

opacity 4-8 mm in diameter presumed to

representa pulmonary acinus rendered opaque

by consolidation This term is usually used in the presence of many such opacities

2 Consolidation

The process by which air in the lung is

replaced by the products of disease rendering the

lung solid (as in the case of pneumonia)

Radiographically consolidation is seen as

relatively homogeneous

opacity in the lung with little or no volume loss

effacement of pulmonary blood vessels and

sometimes the presence of the air bronchogram

3 Air bronchogram

4 Butterfly or Batrsquos wings distribution

Ex

- Pulmonary edema

- Pneumonia

- Pneumocystis infection

- Intraalveolar hemorrhage

bull Predominately interstitial disease

1 Septal pattern

ex Hydrostatic pulmonary edema malignancy

- Kerley A line

- Kerley B line

2 Reticular pattern

ex Asbestosis Idiopathic pulmonary fibrosis

3 Nodular pattern

ex Silicosis Miliary fungal infection

4 Reticulonodular pattern

ex Langerhansrsquo cell histiocytosis Lymphangitic

carcinomatosis

5 Ground glass pattern

ex PCP pulmonary hemorrhage

Diffuse pulmonary hemorrhage

Chest radiograph shows ground-glass

opacities involving mainly the lower

lung zones The patient was an 18-

year-old woman with diffuse

pulmonary hemorrhage due to vasculitis

bull Parenchymal atelectasis

- Direct sign Displacement of

interlobar fissure (white arrow)

- Indirect sign

ndash Displacement of hilar vessels

ndash Elevation of diaphragm

(black arrow)

ndash Mediastinal shift

ndash Compensatory emphysema

ndash Approximation of the ribs

ndash Tracheal shift (arrowhead)

bull Pneumonia

1 Lobar pneumonia

- Consolidation

- Air bronchogram

- S pneumoniae K pneumonia

2 Round pneumonia

- Soft tissue mass

- Air bronchogram

- Spneumoniae H influenzae

3 Lobular pneumonia

- Multifocal patchy opacities

- Peribronchial infiltration(Thickening of

peribronchial wall)

- Volume loss

- S aureus gram negative bacilli

Mycobacterium tuberculosis Mycoplasma

pneumonia

4Interstitial pneumonia

- Ground glass infiltrationndash PCP

- Peribronchial thickening and perihilar

infiltrationndash Viral pneumonia Mycoplasma

pneumonia

- Reticulonodular shadowing of lunglocalized or

wide spreadmdashPulmonary tuberculosis

- Miliary patternmdashMiliary tuberculosis

bull Pulmonary edema

1 Cardiogenic pulmonary edema

- Interstitial pattern

septal line peribronchial

thickeningsubpleural

pulmonary edema

- Alveolar edema

air space shadow

bat-wing

- Cardiomegaly

2 Non cardiogenic pulmonary edema

- Patchy ill-defined density

- Normal heart

- Normal upper

lobe blood distribution

- No pleural effusion

bull Lung mass

1 Solitary pulmonary nodule

- less than 2 cm

ex Malignant neoplasm Infectious granuloma(TB

Fungus) Benign tumor(hamartoma)

Solitary pulmonary nodule

Cavitating nodule secondary to an abscess

2 Multiple nodule

- small sized nodule(2-5 mm)

ex Pulmonary tuberculosis

- medium sized nodule(5-20 mm)

ex Metastatic lesion

- large sized nodule(gt20 mm) ex Lung metastatic

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

bull Cervicothoracic sign

The location of a lesion at the inlet of the thoracic cavity In this anatomical space the posterior portions of the lung apices are located more superiorly than the anterior portions For this reason a lesion clearly visible above the clavicles on the frontal view must lie posteriorly and be entirely within the thorax If the cranial border of the lesion is obscured at or below the level of the clavicles it is located at the anterior mediastinum The borders are not clearly delineated because the lesion is far from the air filled lung and there are cervical soft tissues at this level

Radiological lung disease

bull Predominately airspace disease

1 Acinar shadow

A round or ovoid poorly defined pulmonary

opacity 4-8 mm in diameter presumed to

representa pulmonary acinus rendered opaque

by consolidation This term is usually used in the presence of many such opacities

2 Consolidation

The process by which air in the lung is

replaced by the products of disease rendering the

lung solid (as in the case of pneumonia)

Radiographically consolidation is seen as

relatively homogeneous

opacity in the lung with little or no volume loss

effacement of pulmonary blood vessels and

sometimes the presence of the air bronchogram

3 Air bronchogram

4 Butterfly or Batrsquos wings distribution

Ex

- Pulmonary edema

- Pneumonia

- Pneumocystis infection

- Intraalveolar hemorrhage

bull Predominately interstitial disease

1 Septal pattern

ex Hydrostatic pulmonary edema malignancy

- Kerley A line

- Kerley B line

2 Reticular pattern

ex Asbestosis Idiopathic pulmonary fibrosis

3 Nodular pattern

ex Silicosis Miliary fungal infection

4 Reticulonodular pattern

ex Langerhansrsquo cell histiocytosis Lymphangitic

carcinomatosis

5 Ground glass pattern

ex PCP pulmonary hemorrhage

Diffuse pulmonary hemorrhage

Chest radiograph shows ground-glass

opacities involving mainly the lower

lung zones The patient was an 18-

year-old woman with diffuse

pulmonary hemorrhage due to vasculitis

bull Parenchymal atelectasis

- Direct sign Displacement of

interlobar fissure (white arrow)

- Indirect sign

ndash Displacement of hilar vessels

ndash Elevation of diaphragm

(black arrow)

ndash Mediastinal shift

ndash Compensatory emphysema

ndash Approximation of the ribs

ndash Tracheal shift (arrowhead)

bull Pneumonia

1 Lobar pneumonia

- Consolidation

- Air bronchogram

- S pneumoniae K pneumonia

2 Round pneumonia

- Soft tissue mass

- Air bronchogram

- Spneumoniae H influenzae

3 Lobular pneumonia

- Multifocal patchy opacities

- Peribronchial infiltration(Thickening of

peribronchial wall)

- Volume loss

- S aureus gram negative bacilli

Mycobacterium tuberculosis Mycoplasma

pneumonia

4Interstitial pneumonia

- Ground glass infiltrationndash PCP

- Peribronchial thickening and perihilar

infiltrationndash Viral pneumonia Mycoplasma

pneumonia

- Reticulonodular shadowing of lunglocalized or

wide spreadmdashPulmonary tuberculosis

- Miliary patternmdashMiliary tuberculosis

bull Pulmonary edema

1 Cardiogenic pulmonary edema

- Interstitial pattern

septal line peribronchial

thickeningsubpleural

pulmonary edema

- Alveolar edema

air space shadow

bat-wing

- Cardiomegaly

2 Non cardiogenic pulmonary edema

- Patchy ill-defined density

- Normal heart

- Normal upper

lobe blood distribution

- No pleural effusion

bull Lung mass

1 Solitary pulmonary nodule

- less than 2 cm

ex Malignant neoplasm Infectious granuloma(TB

Fungus) Benign tumor(hamartoma)

Solitary pulmonary nodule

Cavitating nodule secondary to an abscess

2 Multiple nodule

- small sized nodule(2-5 mm)

ex Pulmonary tuberculosis

- medium sized nodule(5-20 mm)

ex Metastatic lesion

- large sized nodule(gt20 mm) ex Lung metastatic

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Radiological lung disease

bull Predominately airspace disease

1 Acinar shadow

A round or ovoid poorly defined pulmonary

opacity 4-8 mm in diameter presumed to

representa pulmonary acinus rendered opaque

by consolidation This term is usually used in the presence of many such opacities

2 Consolidation

The process by which air in the lung is

replaced by the products of disease rendering the

lung solid (as in the case of pneumonia)

Radiographically consolidation is seen as

relatively homogeneous

opacity in the lung with little or no volume loss

effacement of pulmonary blood vessels and

sometimes the presence of the air bronchogram

3 Air bronchogram

4 Butterfly or Batrsquos wings distribution

Ex

- Pulmonary edema

- Pneumonia

- Pneumocystis infection

- Intraalveolar hemorrhage

bull Predominately interstitial disease

1 Septal pattern

ex Hydrostatic pulmonary edema malignancy

- Kerley A line

- Kerley B line

2 Reticular pattern

ex Asbestosis Idiopathic pulmonary fibrosis

3 Nodular pattern

ex Silicosis Miliary fungal infection

4 Reticulonodular pattern

ex Langerhansrsquo cell histiocytosis Lymphangitic

carcinomatosis

5 Ground glass pattern

ex PCP pulmonary hemorrhage

Diffuse pulmonary hemorrhage

Chest radiograph shows ground-glass

opacities involving mainly the lower

lung zones The patient was an 18-

year-old woman with diffuse

pulmonary hemorrhage due to vasculitis

bull Parenchymal atelectasis

- Direct sign Displacement of

interlobar fissure (white arrow)

- Indirect sign

ndash Displacement of hilar vessels

ndash Elevation of diaphragm

(black arrow)

ndash Mediastinal shift

ndash Compensatory emphysema

ndash Approximation of the ribs

ndash Tracheal shift (arrowhead)

bull Pneumonia

1 Lobar pneumonia

- Consolidation

- Air bronchogram

- S pneumoniae K pneumonia

2 Round pneumonia

- Soft tissue mass

- Air bronchogram

- Spneumoniae H influenzae

3 Lobular pneumonia

- Multifocal patchy opacities

- Peribronchial infiltration(Thickening of

peribronchial wall)

- Volume loss

- S aureus gram negative bacilli

Mycobacterium tuberculosis Mycoplasma

pneumonia

4Interstitial pneumonia

- Ground glass infiltrationndash PCP

- Peribronchial thickening and perihilar

infiltrationndash Viral pneumonia Mycoplasma

pneumonia

- Reticulonodular shadowing of lunglocalized or

wide spreadmdashPulmonary tuberculosis

- Miliary patternmdashMiliary tuberculosis

bull Pulmonary edema

1 Cardiogenic pulmonary edema

- Interstitial pattern

septal line peribronchial

thickeningsubpleural

pulmonary edema

- Alveolar edema

air space shadow

bat-wing

- Cardiomegaly

2 Non cardiogenic pulmonary edema

- Patchy ill-defined density

- Normal heart

- Normal upper

lobe blood distribution

- No pleural effusion

bull Lung mass

1 Solitary pulmonary nodule

- less than 2 cm

ex Malignant neoplasm Infectious granuloma(TB

Fungus) Benign tumor(hamartoma)

Solitary pulmonary nodule

Cavitating nodule secondary to an abscess

2 Multiple nodule

- small sized nodule(2-5 mm)

ex Pulmonary tuberculosis

- medium sized nodule(5-20 mm)

ex Metastatic lesion

- large sized nodule(gt20 mm) ex Lung metastatic

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

2 Consolidation

The process by which air in the lung is

replaced by the products of disease rendering the

lung solid (as in the case of pneumonia)

Radiographically consolidation is seen as

relatively homogeneous

opacity in the lung with little or no volume loss

effacement of pulmonary blood vessels and

sometimes the presence of the air bronchogram

3 Air bronchogram

4 Butterfly or Batrsquos wings distribution

Ex

- Pulmonary edema

- Pneumonia

- Pneumocystis infection

- Intraalveolar hemorrhage

bull Predominately interstitial disease

1 Septal pattern

ex Hydrostatic pulmonary edema malignancy

- Kerley A line

- Kerley B line

2 Reticular pattern

ex Asbestosis Idiopathic pulmonary fibrosis

3 Nodular pattern

ex Silicosis Miliary fungal infection

4 Reticulonodular pattern

ex Langerhansrsquo cell histiocytosis Lymphangitic

carcinomatosis

5 Ground glass pattern

ex PCP pulmonary hemorrhage

Diffuse pulmonary hemorrhage

Chest radiograph shows ground-glass

opacities involving mainly the lower

lung zones The patient was an 18-

year-old woman with diffuse

pulmonary hemorrhage due to vasculitis

bull Parenchymal atelectasis

- Direct sign Displacement of

interlobar fissure (white arrow)

- Indirect sign

ndash Displacement of hilar vessels

ndash Elevation of diaphragm

(black arrow)

ndash Mediastinal shift

ndash Compensatory emphysema

ndash Approximation of the ribs

ndash Tracheal shift (arrowhead)

bull Pneumonia

1 Lobar pneumonia

- Consolidation

- Air bronchogram

- S pneumoniae K pneumonia

2 Round pneumonia

- Soft tissue mass

- Air bronchogram

- Spneumoniae H influenzae

3 Lobular pneumonia

- Multifocal patchy opacities

- Peribronchial infiltration(Thickening of

peribronchial wall)

- Volume loss

- S aureus gram negative bacilli

Mycobacterium tuberculosis Mycoplasma

pneumonia

4Interstitial pneumonia

- Ground glass infiltrationndash PCP

- Peribronchial thickening and perihilar

infiltrationndash Viral pneumonia Mycoplasma

pneumonia

- Reticulonodular shadowing of lunglocalized or

wide spreadmdashPulmonary tuberculosis

- Miliary patternmdashMiliary tuberculosis

bull Pulmonary edema

1 Cardiogenic pulmonary edema

- Interstitial pattern

septal line peribronchial

thickeningsubpleural

pulmonary edema

- Alveolar edema

air space shadow

bat-wing

- Cardiomegaly

2 Non cardiogenic pulmonary edema

- Patchy ill-defined density

- Normal heart

- Normal upper

lobe blood distribution

- No pleural effusion

bull Lung mass

1 Solitary pulmonary nodule

- less than 2 cm

ex Malignant neoplasm Infectious granuloma(TB

Fungus) Benign tumor(hamartoma)

Solitary pulmonary nodule

Cavitating nodule secondary to an abscess

2 Multiple nodule

- small sized nodule(2-5 mm)

ex Pulmonary tuberculosis

- medium sized nodule(5-20 mm)

ex Metastatic lesion

- large sized nodule(gt20 mm) ex Lung metastatic

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

3 Air bronchogram

4 Butterfly or Batrsquos wings distribution

Ex

- Pulmonary edema

- Pneumonia

- Pneumocystis infection

- Intraalveolar hemorrhage

bull Predominately interstitial disease

1 Septal pattern

ex Hydrostatic pulmonary edema malignancy

- Kerley A line

- Kerley B line

2 Reticular pattern

ex Asbestosis Idiopathic pulmonary fibrosis

3 Nodular pattern

ex Silicosis Miliary fungal infection

4 Reticulonodular pattern

ex Langerhansrsquo cell histiocytosis Lymphangitic

carcinomatosis

5 Ground glass pattern

ex PCP pulmonary hemorrhage

Diffuse pulmonary hemorrhage

Chest radiograph shows ground-glass

opacities involving mainly the lower

lung zones The patient was an 18-

year-old woman with diffuse

pulmonary hemorrhage due to vasculitis

bull Parenchymal atelectasis

- Direct sign Displacement of

interlobar fissure (white arrow)

- Indirect sign

ndash Displacement of hilar vessels

ndash Elevation of diaphragm

(black arrow)

ndash Mediastinal shift

ndash Compensatory emphysema

ndash Approximation of the ribs

ndash Tracheal shift (arrowhead)

bull Pneumonia

1 Lobar pneumonia

- Consolidation

- Air bronchogram

- S pneumoniae K pneumonia

2 Round pneumonia

- Soft tissue mass

- Air bronchogram

- Spneumoniae H influenzae

3 Lobular pneumonia

- Multifocal patchy opacities

- Peribronchial infiltration(Thickening of

peribronchial wall)

- Volume loss

- S aureus gram negative bacilli

Mycobacterium tuberculosis Mycoplasma

pneumonia

4Interstitial pneumonia

- Ground glass infiltrationndash PCP

- Peribronchial thickening and perihilar

infiltrationndash Viral pneumonia Mycoplasma

pneumonia

- Reticulonodular shadowing of lunglocalized or

wide spreadmdashPulmonary tuberculosis

- Miliary patternmdashMiliary tuberculosis

bull Pulmonary edema

1 Cardiogenic pulmonary edema

- Interstitial pattern

septal line peribronchial

thickeningsubpleural

pulmonary edema

- Alveolar edema

air space shadow

bat-wing

- Cardiomegaly

2 Non cardiogenic pulmonary edema

- Patchy ill-defined density

- Normal heart

- Normal upper

lobe blood distribution

- No pleural effusion

bull Lung mass

1 Solitary pulmonary nodule

- less than 2 cm

ex Malignant neoplasm Infectious granuloma(TB

Fungus) Benign tumor(hamartoma)

Solitary pulmonary nodule

Cavitating nodule secondary to an abscess

2 Multiple nodule

- small sized nodule(2-5 mm)

ex Pulmonary tuberculosis

- medium sized nodule(5-20 mm)

ex Metastatic lesion

- large sized nodule(gt20 mm) ex Lung metastatic

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Ex

- Pulmonary edema

- Pneumonia

- Pneumocystis infection

- Intraalveolar hemorrhage

bull Predominately interstitial disease

1 Septal pattern

ex Hydrostatic pulmonary edema malignancy

- Kerley A line

- Kerley B line

2 Reticular pattern

ex Asbestosis Idiopathic pulmonary fibrosis

3 Nodular pattern

ex Silicosis Miliary fungal infection

4 Reticulonodular pattern

ex Langerhansrsquo cell histiocytosis Lymphangitic

carcinomatosis

5 Ground glass pattern

ex PCP pulmonary hemorrhage

Diffuse pulmonary hemorrhage

Chest radiograph shows ground-glass

opacities involving mainly the lower

lung zones The patient was an 18-

year-old woman with diffuse

pulmonary hemorrhage due to vasculitis

bull Parenchymal atelectasis

- Direct sign Displacement of

interlobar fissure (white arrow)

- Indirect sign

ndash Displacement of hilar vessels

ndash Elevation of diaphragm

(black arrow)

ndash Mediastinal shift

ndash Compensatory emphysema

ndash Approximation of the ribs

ndash Tracheal shift (arrowhead)

bull Pneumonia

1 Lobar pneumonia

- Consolidation

- Air bronchogram

- S pneumoniae K pneumonia

2 Round pneumonia

- Soft tissue mass

- Air bronchogram

- Spneumoniae H influenzae

3 Lobular pneumonia

- Multifocal patchy opacities

- Peribronchial infiltration(Thickening of

peribronchial wall)

- Volume loss

- S aureus gram negative bacilli

Mycobacterium tuberculosis Mycoplasma

pneumonia

4Interstitial pneumonia

- Ground glass infiltrationndash PCP

- Peribronchial thickening and perihilar

infiltrationndash Viral pneumonia Mycoplasma

pneumonia

- Reticulonodular shadowing of lunglocalized or

wide spreadmdashPulmonary tuberculosis

- Miliary patternmdashMiliary tuberculosis

bull Pulmonary edema

1 Cardiogenic pulmonary edema

- Interstitial pattern

septal line peribronchial

thickeningsubpleural

pulmonary edema

- Alveolar edema

air space shadow

bat-wing

- Cardiomegaly

2 Non cardiogenic pulmonary edema

- Patchy ill-defined density

- Normal heart

- Normal upper

lobe blood distribution

- No pleural effusion

bull Lung mass

1 Solitary pulmonary nodule

- less than 2 cm

ex Malignant neoplasm Infectious granuloma(TB

Fungus) Benign tumor(hamartoma)

Solitary pulmonary nodule

Cavitating nodule secondary to an abscess

2 Multiple nodule

- small sized nodule(2-5 mm)

ex Pulmonary tuberculosis

- medium sized nodule(5-20 mm)

ex Metastatic lesion

- large sized nodule(gt20 mm) ex Lung metastatic

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

bull Predominately interstitial disease

1 Septal pattern

ex Hydrostatic pulmonary edema malignancy

- Kerley A line

- Kerley B line

2 Reticular pattern

ex Asbestosis Idiopathic pulmonary fibrosis

3 Nodular pattern

ex Silicosis Miliary fungal infection

4 Reticulonodular pattern

ex Langerhansrsquo cell histiocytosis Lymphangitic

carcinomatosis

5 Ground glass pattern

ex PCP pulmonary hemorrhage

Diffuse pulmonary hemorrhage

Chest radiograph shows ground-glass

opacities involving mainly the lower

lung zones The patient was an 18-

year-old woman with diffuse

pulmonary hemorrhage due to vasculitis

bull Parenchymal atelectasis

- Direct sign Displacement of

interlobar fissure (white arrow)

- Indirect sign

ndash Displacement of hilar vessels

ndash Elevation of diaphragm

(black arrow)

ndash Mediastinal shift

ndash Compensatory emphysema

ndash Approximation of the ribs

ndash Tracheal shift (arrowhead)

bull Pneumonia

1 Lobar pneumonia

- Consolidation

- Air bronchogram

- S pneumoniae K pneumonia

2 Round pneumonia

- Soft tissue mass

- Air bronchogram

- Spneumoniae H influenzae

3 Lobular pneumonia

- Multifocal patchy opacities

- Peribronchial infiltration(Thickening of

peribronchial wall)

- Volume loss

- S aureus gram negative bacilli

Mycobacterium tuberculosis Mycoplasma

pneumonia

4Interstitial pneumonia

- Ground glass infiltrationndash PCP

- Peribronchial thickening and perihilar

infiltrationndash Viral pneumonia Mycoplasma

pneumonia

- Reticulonodular shadowing of lunglocalized or

wide spreadmdashPulmonary tuberculosis

- Miliary patternmdashMiliary tuberculosis

bull Pulmonary edema

1 Cardiogenic pulmonary edema

- Interstitial pattern

septal line peribronchial

thickeningsubpleural

pulmonary edema

- Alveolar edema

air space shadow

bat-wing

- Cardiomegaly

2 Non cardiogenic pulmonary edema

- Patchy ill-defined density

- Normal heart

- Normal upper

lobe blood distribution

- No pleural effusion

bull Lung mass

1 Solitary pulmonary nodule

- less than 2 cm

ex Malignant neoplasm Infectious granuloma(TB

Fungus) Benign tumor(hamartoma)

Solitary pulmonary nodule

Cavitating nodule secondary to an abscess

2 Multiple nodule

- small sized nodule(2-5 mm)

ex Pulmonary tuberculosis

- medium sized nodule(5-20 mm)

ex Metastatic lesion

- large sized nodule(gt20 mm) ex Lung metastatic

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

2 Reticular pattern

ex Asbestosis Idiopathic pulmonary fibrosis

3 Nodular pattern

ex Silicosis Miliary fungal infection

4 Reticulonodular pattern

ex Langerhansrsquo cell histiocytosis Lymphangitic

carcinomatosis

5 Ground glass pattern

ex PCP pulmonary hemorrhage

Diffuse pulmonary hemorrhage

Chest radiograph shows ground-glass

opacities involving mainly the lower

lung zones The patient was an 18-

year-old woman with diffuse

pulmonary hemorrhage due to vasculitis

bull Parenchymal atelectasis

- Direct sign Displacement of

interlobar fissure (white arrow)

- Indirect sign

ndash Displacement of hilar vessels

ndash Elevation of diaphragm

(black arrow)

ndash Mediastinal shift

ndash Compensatory emphysema

ndash Approximation of the ribs

ndash Tracheal shift (arrowhead)

bull Pneumonia

1 Lobar pneumonia

- Consolidation

- Air bronchogram

- S pneumoniae K pneumonia

2 Round pneumonia

- Soft tissue mass

- Air bronchogram

- Spneumoniae H influenzae

3 Lobular pneumonia

- Multifocal patchy opacities

- Peribronchial infiltration(Thickening of

peribronchial wall)

- Volume loss

- S aureus gram negative bacilli

Mycobacterium tuberculosis Mycoplasma

pneumonia

4Interstitial pneumonia

- Ground glass infiltrationndash PCP

- Peribronchial thickening and perihilar

infiltrationndash Viral pneumonia Mycoplasma

pneumonia

- Reticulonodular shadowing of lunglocalized or

wide spreadmdashPulmonary tuberculosis

- Miliary patternmdashMiliary tuberculosis

bull Pulmonary edema

1 Cardiogenic pulmonary edema

- Interstitial pattern

septal line peribronchial

thickeningsubpleural

pulmonary edema

- Alveolar edema

air space shadow

bat-wing

- Cardiomegaly

2 Non cardiogenic pulmonary edema

- Patchy ill-defined density

- Normal heart

- Normal upper

lobe blood distribution

- No pleural effusion

bull Lung mass

1 Solitary pulmonary nodule

- less than 2 cm

ex Malignant neoplasm Infectious granuloma(TB

Fungus) Benign tumor(hamartoma)

Solitary pulmonary nodule

Cavitating nodule secondary to an abscess

2 Multiple nodule

- small sized nodule(2-5 mm)

ex Pulmonary tuberculosis

- medium sized nodule(5-20 mm)

ex Metastatic lesion

- large sized nodule(gt20 mm) ex Lung metastatic

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

3 Nodular pattern

ex Silicosis Miliary fungal infection

4 Reticulonodular pattern

ex Langerhansrsquo cell histiocytosis Lymphangitic

carcinomatosis

5 Ground glass pattern

ex PCP pulmonary hemorrhage

Diffuse pulmonary hemorrhage

Chest radiograph shows ground-glass

opacities involving mainly the lower

lung zones The patient was an 18-

year-old woman with diffuse

pulmonary hemorrhage due to vasculitis

bull Parenchymal atelectasis

- Direct sign Displacement of

interlobar fissure (white arrow)

- Indirect sign

ndash Displacement of hilar vessels

ndash Elevation of diaphragm

(black arrow)

ndash Mediastinal shift

ndash Compensatory emphysema

ndash Approximation of the ribs

ndash Tracheal shift (arrowhead)

bull Pneumonia

1 Lobar pneumonia

- Consolidation

- Air bronchogram

- S pneumoniae K pneumonia

2 Round pneumonia

- Soft tissue mass

- Air bronchogram

- Spneumoniae H influenzae

3 Lobular pneumonia

- Multifocal patchy opacities

- Peribronchial infiltration(Thickening of

peribronchial wall)

- Volume loss

- S aureus gram negative bacilli

Mycobacterium tuberculosis Mycoplasma

pneumonia

4Interstitial pneumonia

- Ground glass infiltrationndash PCP

- Peribronchial thickening and perihilar

infiltrationndash Viral pneumonia Mycoplasma

pneumonia

- Reticulonodular shadowing of lunglocalized or

wide spreadmdashPulmonary tuberculosis

- Miliary patternmdashMiliary tuberculosis

bull Pulmonary edema

1 Cardiogenic pulmonary edema

- Interstitial pattern

septal line peribronchial

thickeningsubpleural

pulmonary edema

- Alveolar edema

air space shadow

bat-wing

- Cardiomegaly

2 Non cardiogenic pulmonary edema

- Patchy ill-defined density

- Normal heart

- Normal upper

lobe blood distribution

- No pleural effusion

bull Lung mass

1 Solitary pulmonary nodule

- less than 2 cm

ex Malignant neoplasm Infectious granuloma(TB

Fungus) Benign tumor(hamartoma)

Solitary pulmonary nodule

Cavitating nodule secondary to an abscess

2 Multiple nodule

- small sized nodule(2-5 mm)

ex Pulmonary tuberculosis

- medium sized nodule(5-20 mm)

ex Metastatic lesion

- large sized nodule(gt20 mm) ex Lung metastatic

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

4 Reticulonodular pattern

ex Langerhansrsquo cell histiocytosis Lymphangitic

carcinomatosis

5 Ground glass pattern

ex PCP pulmonary hemorrhage

Diffuse pulmonary hemorrhage

Chest radiograph shows ground-glass

opacities involving mainly the lower

lung zones The patient was an 18-

year-old woman with diffuse

pulmonary hemorrhage due to vasculitis

bull Parenchymal atelectasis

- Direct sign Displacement of

interlobar fissure (white arrow)

- Indirect sign

ndash Displacement of hilar vessels

ndash Elevation of diaphragm

(black arrow)

ndash Mediastinal shift

ndash Compensatory emphysema

ndash Approximation of the ribs

ndash Tracheal shift (arrowhead)

bull Pneumonia

1 Lobar pneumonia

- Consolidation

- Air bronchogram

- S pneumoniae K pneumonia

2 Round pneumonia

- Soft tissue mass

- Air bronchogram

- Spneumoniae H influenzae

3 Lobular pneumonia

- Multifocal patchy opacities

- Peribronchial infiltration(Thickening of

peribronchial wall)

- Volume loss

- S aureus gram negative bacilli

Mycobacterium tuberculosis Mycoplasma

pneumonia

4Interstitial pneumonia

- Ground glass infiltrationndash PCP

- Peribronchial thickening and perihilar

infiltrationndash Viral pneumonia Mycoplasma

pneumonia

- Reticulonodular shadowing of lunglocalized or

wide spreadmdashPulmonary tuberculosis

- Miliary patternmdashMiliary tuberculosis

bull Pulmonary edema

1 Cardiogenic pulmonary edema

- Interstitial pattern

septal line peribronchial

thickeningsubpleural

pulmonary edema

- Alveolar edema

air space shadow

bat-wing

- Cardiomegaly

2 Non cardiogenic pulmonary edema

- Patchy ill-defined density

- Normal heart

- Normal upper

lobe blood distribution

- No pleural effusion

bull Lung mass

1 Solitary pulmonary nodule

- less than 2 cm

ex Malignant neoplasm Infectious granuloma(TB

Fungus) Benign tumor(hamartoma)

Solitary pulmonary nodule

Cavitating nodule secondary to an abscess

2 Multiple nodule

- small sized nodule(2-5 mm)

ex Pulmonary tuberculosis

- medium sized nodule(5-20 mm)

ex Metastatic lesion

- large sized nodule(gt20 mm) ex Lung metastatic

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

5 Ground glass pattern

ex PCP pulmonary hemorrhage

Diffuse pulmonary hemorrhage

Chest radiograph shows ground-glass

opacities involving mainly the lower

lung zones The patient was an 18-

year-old woman with diffuse

pulmonary hemorrhage due to vasculitis

bull Parenchymal atelectasis

- Direct sign Displacement of

interlobar fissure (white arrow)

- Indirect sign

ndash Displacement of hilar vessels

ndash Elevation of diaphragm

(black arrow)

ndash Mediastinal shift

ndash Compensatory emphysema

ndash Approximation of the ribs

ndash Tracheal shift (arrowhead)

bull Pneumonia

1 Lobar pneumonia

- Consolidation

- Air bronchogram

- S pneumoniae K pneumonia

2 Round pneumonia

- Soft tissue mass

- Air bronchogram

- Spneumoniae H influenzae

3 Lobular pneumonia

- Multifocal patchy opacities

- Peribronchial infiltration(Thickening of

peribronchial wall)

- Volume loss

- S aureus gram negative bacilli

Mycobacterium tuberculosis Mycoplasma

pneumonia

4Interstitial pneumonia

- Ground glass infiltrationndash PCP

- Peribronchial thickening and perihilar

infiltrationndash Viral pneumonia Mycoplasma

pneumonia

- Reticulonodular shadowing of lunglocalized or

wide spreadmdashPulmonary tuberculosis

- Miliary patternmdashMiliary tuberculosis

bull Pulmonary edema

1 Cardiogenic pulmonary edema

- Interstitial pattern

septal line peribronchial

thickeningsubpleural

pulmonary edema

- Alveolar edema

air space shadow

bat-wing

- Cardiomegaly

2 Non cardiogenic pulmonary edema

- Patchy ill-defined density

- Normal heart

- Normal upper

lobe blood distribution

- No pleural effusion

bull Lung mass

1 Solitary pulmonary nodule

- less than 2 cm

ex Malignant neoplasm Infectious granuloma(TB

Fungus) Benign tumor(hamartoma)

Solitary pulmonary nodule

Cavitating nodule secondary to an abscess

2 Multiple nodule

- small sized nodule(2-5 mm)

ex Pulmonary tuberculosis

- medium sized nodule(5-20 mm)

ex Metastatic lesion

- large sized nodule(gt20 mm) ex Lung metastatic

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

bull Parenchymal atelectasis

- Direct sign Displacement of

interlobar fissure (white arrow)

- Indirect sign

ndash Displacement of hilar vessels

ndash Elevation of diaphragm

(black arrow)

ndash Mediastinal shift

ndash Compensatory emphysema

ndash Approximation of the ribs

ndash Tracheal shift (arrowhead)

bull Pneumonia

1 Lobar pneumonia

- Consolidation

- Air bronchogram

- S pneumoniae K pneumonia

2 Round pneumonia

- Soft tissue mass

- Air bronchogram

- Spneumoniae H influenzae

3 Lobular pneumonia

- Multifocal patchy opacities

- Peribronchial infiltration(Thickening of

peribronchial wall)

- Volume loss

- S aureus gram negative bacilli

Mycobacterium tuberculosis Mycoplasma

pneumonia

4Interstitial pneumonia

- Ground glass infiltrationndash PCP

- Peribronchial thickening and perihilar

infiltrationndash Viral pneumonia Mycoplasma

pneumonia

- Reticulonodular shadowing of lunglocalized or

wide spreadmdashPulmonary tuberculosis

- Miliary patternmdashMiliary tuberculosis

bull Pulmonary edema

1 Cardiogenic pulmonary edema

- Interstitial pattern

septal line peribronchial

thickeningsubpleural

pulmonary edema

- Alveolar edema

air space shadow

bat-wing

- Cardiomegaly

2 Non cardiogenic pulmonary edema

- Patchy ill-defined density

- Normal heart

- Normal upper

lobe blood distribution

- No pleural effusion

bull Lung mass

1 Solitary pulmonary nodule

- less than 2 cm

ex Malignant neoplasm Infectious granuloma(TB

Fungus) Benign tumor(hamartoma)

Solitary pulmonary nodule

Cavitating nodule secondary to an abscess

2 Multiple nodule

- small sized nodule(2-5 mm)

ex Pulmonary tuberculosis

- medium sized nodule(5-20 mm)

ex Metastatic lesion

- large sized nodule(gt20 mm) ex Lung metastatic

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

bull Pneumonia

1 Lobar pneumonia

- Consolidation

- Air bronchogram

- S pneumoniae K pneumonia

2 Round pneumonia

- Soft tissue mass

- Air bronchogram

- Spneumoniae H influenzae

3 Lobular pneumonia

- Multifocal patchy opacities

- Peribronchial infiltration(Thickening of

peribronchial wall)

- Volume loss

- S aureus gram negative bacilli

Mycobacterium tuberculosis Mycoplasma

pneumonia

4Interstitial pneumonia

- Ground glass infiltrationndash PCP

- Peribronchial thickening and perihilar

infiltrationndash Viral pneumonia Mycoplasma

pneumonia

- Reticulonodular shadowing of lunglocalized or

wide spreadmdashPulmonary tuberculosis

- Miliary patternmdashMiliary tuberculosis

bull Pulmonary edema

1 Cardiogenic pulmonary edema

- Interstitial pattern

septal line peribronchial

thickeningsubpleural

pulmonary edema

- Alveolar edema

air space shadow

bat-wing

- Cardiomegaly

2 Non cardiogenic pulmonary edema

- Patchy ill-defined density

- Normal heart

- Normal upper

lobe blood distribution

- No pleural effusion

bull Lung mass

1 Solitary pulmonary nodule

- less than 2 cm

ex Malignant neoplasm Infectious granuloma(TB

Fungus) Benign tumor(hamartoma)

Solitary pulmonary nodule

Cavitating nodule secondary to an abscess

2 Multiple nodule

- small sized nodule(2-5 mm)

ex Pulmonary tuberculosis

- medium sized nodule(5-20 mm)

ex Metastatic lesion

- large sized nodule(gt20 mm) ex Lung metastatic

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

2 Round pneumonia

- Soft tissue mass

- Air bronchogram

- Spneumoniae H influenzae

3 Lobular pneumonia

- Multifocal patchy opacities

- Peribronchial infiltration(Thickening of

peribronchial wall)

- Volume loss

- S aureus gram negative bacilli

Mycobacterium tuberculosis Mycoplasma

pneumonia

4Interstitial pneumonia

- Ground glass infiltrationndash PCP

- Peribronchial thickening and perihilar

infiltrationndash Viral pneumonia Mycoplasma

pneumonia

- Reticulonodular shadowing of lunglocalized or

wide spreadmdashPulmonary tuberculosis

- Miliary patternmdashMiliary tuberculosis

bull Pulmonary edema

1 Cardiogenic pulmonary edema

- Interstitial pattern

septal line peribronchial

thickeningsubpleural

pulmonary edema

- Alveolar edema

air space shadow

bat-wing

- Cardiomegaly

2 Non cardiogenic pulmonary edema

- Patchy ill-defined density

- Normal heart

- Normal upper

lobe blood distribution

- No pleural effusion

bull Lung mass

1 Solitary pulmonary nodule

- less than 2 cm

ex Malignant neoplasm Infectious granuloma(TB

Fungus) Benign tumor(hamartoma)

Solitary pulmonary nodule

Cavitating nodule secondary to an abscess

2 Multiple nodule

- small sized nodule(2-5 mm)

ex Pulmonary tuberculosis

- medium sized nodule(5-20 mm)

ex Metastatic lesion

- large sized nodule(gt20 mm) ex Lung metastatic

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

3 Lobular pneumonia

- Multifocal patchy opacities

- Peribronchial infiltration(Thickening of

peribronchial wall)

- Volume loss

- S aureus gram negative bacilli

Mycobacterium tuberculosis Mycoplasma

pneumonia

4Interstitial pneumonia

- Ground glass infiltrationndash PCP

- Peribronchial thickening and perihilar

infiltrationndash Viral pneumonia Mycoplasma

pneumonia

- Reticulonodular shadowing of lunglocalized or

wide spreadmdashPulmonary tuberculosis

- Miliary patternmdashMiliary tuberculosis

bull Pulmonary edema

1 Cardiogenic pulmonary edema

- Interstitial pattern

septal line peribronchial

thickeningsubpleural

pulmonary edema

- Alveolar edema

air space shadow

bat-wing

- Cardiomegaly

2 Non cardiogenic pulmonary edema

- Patchy ill-defined density

- Normal heart

- Normal upper

lobe blood distribution

- No pleural effusion

bull Lung mass

1 Solitary pulmonary nodule

- less than 2 cm

ex Malignant neoplasm Infectious granuloma(TB

Fungus) Benign tumor(hamartoma)

Solitary pulmonary nodule

Cavitating nodule secondary to an abscess

2 Multiple nodule

- small sized nodule(2-5 mm)

ex Pulmonary tuberculosis

- medium sized nodule(5-20 mm)

ex Metastatic lesion

- large sized nodule(gt20 mm) ex Lung metastatic

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

4Interstitial pneumonia

- Ground glass infiltrationndash PCP

- Peribronchial thickening and perihilar

infiltrationndash Viral pneumonia Mycoplasma

pneumonia

- Reticulonodular shadowing of lunglocalized or

wide spreadmdashPulmonary tuberculosis

- Miliary patternmdashMiliary tuberculosis

bull Pulmonary edema

1 Cardiogenic pulmonary edema

- Interstitial pattern

septal line peribronchial

thickeningsubpleural

pulmonary edema

- Alveolar edema

air space shadow

bat-wing

- Cardiomegaly

2 Non cardiogenic pulmonary edema

- Patchy ill-defined density

- Normal heart

- Normal upper

lobe blood distribution

- No pleural effusion

bull Lung mass

1 Solitary pulmonary nodule

- less than 2 cm

ex Malignant neoplasm Infectious granuloma(TB

Fungus) Benign tumor(hamartoma)

Solitary pulmonary nodule

Cavitating nodule secondary to an abscess

2 Multiple nodule

- small sized nodule(2-5 mm)

ex Pulmonary tuberculosis

- medium sized nodule(5-20 mm)

ex Metastatic lesion

- large sized nodule(gt20 mm) ex Lung metastatic

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

bull Pulmonary edema

1 Cardiogenic pulmonary edema

- Interstitial pattern

septal line peribronchial

thickeningsubpleural

pulmonary edema

- Alveolar edema

air space shadow

bat-wing

- Cardiomegaly

2 Non cardiogenic pulmonary edema

- Patchy ill-defined density

- Normal heart

- Normal upper

lobe blood distribution

- No pleural effusion

bull Lung mass

1 Solitary pulmonary nodule

- less than 2 cm

ex Malignant neoplasm Infectious granuloma(TB

Fungus) Benign tumor(hamartoma)

Solitary pulmonary nodule

Cavitating nodule secondary to an abscess

2 Multiple nodule

- small sized nodule(2-5 mm)

ex Pulmonary tuberculosis

- medium sized nodule(5-20 mm)

ex Metastatic lesion

- large sized nodule(gt20 mm) ex Lung metastatic

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

2 Non cardiogenic pulmonary edema

- Patchy ill-defined density

- Normal heart

- Normal upper

lobe blood distribution

- No pleural effusion

bull Lung mass

1 Solitary pulmonary nodule

- less than 2 cm

ex Malignant neoplasm Infectious granuloma(TB

Fungus) Benign tumor(hamartoma)

Solitary pulmonary nodule

Cavitating nodule secondary to an abscess

2 Multiple nodule

- small sized nodule(2-5 mm)

ex Pulmonary tuberculosis

- medium sized nodule(5-20 mm)

ex Metastatic lesion

- large sized nodule(gt20 mm) ex Lung metastatic

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

bull Lung mass

1 Solitary pulmonary nodule

- less than 2 cm

ex Malignant neoplasm Infectious granuloma(TB

Fungus) Benign tumor(hamartoma)

Solitary pulmonary nodule

Cavitating nodule secondary to an abscess

2 Multiple nodule

- small sized nodule(2-5 mm)

ex Pulmonary tuberculosis

- medium sized nodule(5-20 mm)

ex Metastatic lesion

- large sized nodule(gt20 mm) ex Lung metastatic

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

2 Multiple nodule

- small sized nodule(2-5 mm)

ex Pulmonary tuberculosis

- medium sized nodule(5-20 mm)

ex Metastatic lesion

- large sized nodule(gt20 mm) ex Lung metastatic

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

bull Lung cancer

- Golden S sign

- Large spiculated border

- Lobulate or notching

- Eccentric calcification

- Irregular inner wall of cavity

- Multiple lung nodule(Lung to lung metastasis)

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Golden S sign

Central mass

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

bull Cystic and cavitary lesion

- Foci of decreased lung density with definable wall

1 Pulmonary air cyst

- wall lt 4 mm

Ex Post staphylococcal pneumatocele Post traumatic cyst

2 Pulmonary cavitary lesion

- wall gt 4 mm

- air fluid level in active infection

Ex Necrotizing pneumonia Bronchogeniccarcinoma(Squamous cell type)

- Mass in cavitymdashFungal ball

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

bull Airway disease

1 COPD

- Chronic bronchitis

- thickening of

bronchial wall

- Accentuation of

linear opacities through

out the lung

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

- Emphysema

- Overinflation amp flattening of diaphragm (จดสงสดของ dome of diaphragm หางกบเสนสมมตทลากจาก costophrenic to vertebrophrenic junction lt 15 cm)

- Increase retrosternal air space gt3cm วดทระดบ 3cm ต ากวา sternomandibular junction

- Widen rib spaces Decrease lung density Vertical heart shape

lt15cm

gt27cmgt3cm

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

- Bronchiectasis

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Mediastinal mass

bull Anterior- thyroidal mass thymic mass

terratoma lymphoma pericardial cyst

bull Middle- aortic aneurysm lymphadenopathy

esophagus(Achalasia) hiatal hernia

bull Posterior- Nerve sheath tumor extramedullary hematopoietic tissue

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Pleural diseasebull Pleural effusion

- Blunt costophrenic angle

- Tapered margin superiorly

Ex Heart failure inflammation of pleura neoplasm

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

bull Pleural thickening

Ex Infection neoplasm trauma

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

bull Pneumothorax

ndash Air in pleural cavity ―white line of the

visceral pleural volume loss of underlying

lung (passive atelectasis)

ndash Lateral decubitus Upright expired film

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

PLAIN ABDOMEN

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

ABDOMINAL VISCUS

SOLID HOLLOW

Liver

Spleen

Pancreas

KidneysOvaries

Stomach

Small intestine

Large intestine

Gallbladder

Urinary bladderUterus

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

ABDOMINAL QUADRANTS

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

ROENTGEN DENSITIES

1AirGas density

2Fat density

3WaterSoft tissue density

4CalciumBone density

5Metalic density

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

NORMAL FINGINGS

Fat density

bull Peritoneum retroperitoneum pelvis

bull Landmark exproperitoneal fat lines lateralmargin

of psoas muscle kidneys inferior surface of liver

Air density

bull Intestinal gas

Bowel loop

Small or large intestine

Diameter of intestines

Air in rectum

bull Stomach gas LUQ

Soft tissue water density

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

การจดทาผปวย

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Anteroposterior(AP)

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Lateral

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Left posteroanterior oblique

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Bowel perforationbull Bowel perforation is a surgical emergency the X-ray appearances

of pneumoperitoneum

bull Erect chest X-ray should be requested if perforation is suspected

bullThis patient has a large volume of free gas under the diaphragm Dark crescents have formed separating the thin diaphragm from the liver on the right and bowel on the left

bull This patient had a perforated duodenal ulcer

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Riglersdouble wall sign - diagram

bull Normally only the inner wall of the bowel is visible

bull If there is pneumoperitoneum both sides of the bowel wall may be visible

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Riglersdouble wall sign

bull The double wall (Riglers) sign is visible bull Gas separates bowel segments and forms sharp angles and triangles ()

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Football sign

bull 2 radiographs were required to completely cover the abdomen in this large patient

bullA large volume of

free gas has risen to

the front of the

peritoneal cavity

resulting in a large

round black area -football sign

bull The double wall sign (Riglers) is also visible

(arrowhead)

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament or the liver edge

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Abdominal calcification

bullRenal calcification

bullUreteric calcification

bullBladder stones

bullRetroperitoneal calcification

bullViscus calcification

bullArtifact or foreign body

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Renal calcification

Renal collecting systems (calculistones)

90 of renal calculi contain enough calcium to be

visible on abdominal X-rays Urate and matrix stones are not visible

Renal stones are often small but if large can fill the

renal pelvis or a calyx taking on its shape which is

likened to a staghorn

Kidney parenchyma (nephrocalcinosis)

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Staghorn calculus

The irregularly shaped calcific

density has filled and taken on

the form of the right kidney lower pole calyx

Nephrocalcinosis

The renal parenchyma contains

clusters of small calcific

densities

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Ureteric calcification

As with renal stones approximately 90 are visible

Ureteric stones originate as renal stones

May cause renal outflow tract

obstruction which manifests

clinically with severe ipsilateral flankloingroin pain usually with

haematuria

Look carefully for ureteric stones which can be very subtle Dont mistake a transverse process for a stone

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Bladder stone

Bladder stones form in the bladder as a result of urinary stasis

When seen on an abdominalpelvic X-ray they are often multiple

and rounded

Multiple well defined calcific densities are seen within the bladder

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Retroperitoneal calcificationretroperitoneal organs (pancreas or adrenal glands) only become visible when calcified

Adrenal calcification is usually an incidental finding

The adrenal (suprarenal) glands form a

triangle shape lying directly above the kidneys

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

bull Pancreatitis

ndash Acute pancreatitis

อาจเหน adynamic ileus ซงอาจจะเปนเฉพาะท เชน small bowel ileus รอบๆ (sentinel loop) หรอ localized dilatation ของ transverse colon ไปจรด splenicflexure (colon cut-off sign) หรอ generalized adynamic ileus

ไมจ าเพาะ อาจเหนไดในโรคทม abdominal inflammationinfection trauma เชน acute appendicitis acute cholecystitis

อาจไมเหนการเปลยนแปลงจากภาพ x-ray abdomen

ndash Chronic pancreatitis

calcification

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Viscus calcification

Hepatobiliary tree such as in the gallbladder (gallstones)

Gastrointestinal tract such as in the appendix

(appendicolith)

may be mistaken for renal stones

Gallstones

Only 10-15 of gallstones

contain enough calcium to

be visible on an abdominal X-ray

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Appendicoliths are highly

predictive of appendicitis

in patients presenting with right iliac fossa pain

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Artifact or foreign body

medical artifacts

Ingested objects

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Case

bull ผปวยชาย อาย 50 ปbull X-ray Abdomen AP supine

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

bull Disproportion of gas in bowel

bull Small bowel dilate one loop at Right quadrant

(diameter gt 3 cm)

bull Gas filled in small bowel

bull Mottling appearance in stomach (gastric

content)

bull No calcification

bull No free air no sign of perforation

bull Air in colon Partial obstruction

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

แยกลกษณะของล าไสเลกและล าไสใหญ

Small bowel Large bowel

ลกษณะของ fold Fold วงครบวง―valvulae

conniventes

Fold ไมครบวงHaustration

จ านวนของ loop มาก นย

ต าแหนง กลางทอง ดานขาง

รศมการโคงของล าไส เลก ใหญ

อจจาระ ไมพบ พบ

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

bull ผปวยชาย อาย 50 ปbull CC อดแนนทอง 3 สปดาหกอนมาโรงพยาบาลbull Past history ผาตดทางชองทองเมอ 14 ปกอน

bull Dx Partial small bowel obstruction due to adhesion band

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Cause SBO

bull Adhesions

bull Incarcerated hernia

bull Neoplasm

bull Inflammatory bowel disease

bull Volvulus

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

bull distended small bowel loops with prominent valvulae conniventes (small white arrow) diameter gt 3 cm

bull Step ladder pattern

bull Bowel wall between the loops is thickened and edematous (large white arrow)

bull No air is seen in the colon or the rectum

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Step ladder pattern

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Abdomen film Upright position

bull Multiple air-fluid levels in dilated small bowel loops

bull String of bead sign

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Large bowel obstruction

Cause

bull Neoplasm

bull Inflammation eg Diverticulitis

bull Volvulus

bull Hernia

bull Anal stenosis

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

bull Normal transverse colon diameter lt 55 cm

bull Dilatation of colon proximal to the obstruction

bull Decreased gas distal to the obstruction

bull Fluid level in the transverse or Ltsided- colon

bull cecum diameter gt 9 cm prone to perforation

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

bull Gas-filled dilated

large bowel from

cecum to distal

descending colon

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

LBO แบงได 2 แบบ

bull Type 1 Competent ileocecal valve

ndash Type 1A dilate colon and cecum no small bowel

dilate

ndash Type 1B Type 1A ทอดตนนานๆ ท าให small bowel

dilate ได

bull Type 2 Incompetent ileocecal valve

no cecum and ascending colon dilatation

small bowel dilate

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Large bowel volvulus

bull Closed loop obstruction

bull มกพบบรเวณ sigmoid colon cecum transverse

colon

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

bull A large air-filled sigmoid loop arising from the pelvis and extending cranially beyond the level of the transverse colon

bull Inverted U-shaped (Coffee bean sign)

bull Closed loop

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

Gastric outlet obstruction

bull Causes peptic ulcer

carcinoma

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

bull Dilatation of stomach

bull Decreased distal bowel gas

bull Displaced transverse colon

bull Mottling appearance of foods

The End

Thank you

The End

Thank you