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Morgagni Hernia Notes PDF
Morgagni Hernia Notes PDF
A congenital defect in the anteromedial aspect of the diaphragm. At approximately 5% of all diaphragmatic
hernias, Morgagni hernias are much less common than Bochdalek hernias which account for a further 90%. It is
usually just omental fat which is found within the hernia but abdominal viscera can also herniated. (Conversely a
Bochdalek hernia usually contains viscera but can contain just fat). Morgagni hernias tend to be small and
asymptomatic, hence they usually present as incidental findings. The closest differential diagnosis to a
Morgagni hernia would be a cardiac fat pad. Given coronal or sagittal CT slices it should be easy to see the
omental vessels coursing upwards from the abdomen through the diaphragmatic defect. There will be vessels
supplying a cardiac fat pad but these are likely to be far smaller. Granted, the description provided in the
question is deliberately vague.
Bochdalek hernia
A congenital defect in the posterior aspect of the diaphragm which usually (80%) occurs on the left and
accounts for around 90% of all diaphragmatic hernias. They tend to be Big, at the Back (ie posterior), present as
a Baby, contain Bowel, and can be quite Bad since they are associated with pulmonary hypoplasia due to mass
effect. The exact content of the hernia will depend on the laterality. In real life radiology when they occur on the
right they may be as an occult finding of a right lower zone mass silhouetted against the diaphragm. Despite the
classical appearance on a CXR, a CT is usually performed for confirmation.
Pulmonary sequestration
There are two types of pulmonary sequestration and two features which unite them. A segment of lung firstly,
which derives its arterial blood supply from the systemic circulation and secondly, has no communication with
the bronchial tree is termed pulmonary sequestration. It is a congenital abnormality and usually affects the left
lower lobe with a smaller percentage affecting the right lower lobe.
o Intralobar sequestration – This is more common (75%) but less severe. The affected segment does not have its
own pleura and drains, like normal, via the pulmonary veins. Presents as recurrent pneumonias and is seen on a
CXR as cysts with fluid levels. Some are associated with other congenital abnormalities but a larger proportion
develop in isolation.
o Extralobar sequestration – This is less common (25%) and more severe with around half of patients suffering
from other additional congenital anomalies. Venous drainage is via the systemic circulation and patients present
in childhood either with respiratory distress due to shunting of blood or with symptoms attributed to the
associated congenital anomalies (e.g. diaphragmatic hernia). The segment has its own pleura and therefore
collateral air drift via the pores of Kohn cannot occur. The lack of aeration helps differentiate it from intralobar
sequestration. Seen on a CXR as an opacity adjacent to the heart, abutting the diaphragm.
Thymoma
As a differential diagnosis of a thoracic low attenuation lesion, thymomas can be included. They are usually
anterosuperior in location however, although may, if sufficiently large, extend as far down as the diaphragm.
Although they can be surrounded by fat any low attenuation seen within the mass is actually due to necrosis
and fibrosis rather than fat within the mass. They can also contain calcification in amorphous or curvilinear
formations. Features of invasion which would point towards a malignant thymoma as opposed to a benign one
would include an irregular outline, spread along the pleura and invasion of the mediastinal fat.
A 41-year-old lady presents with palpitations. She undergoes an echocardiogram and a subsequent CT
angiogram which demonstrates a 2cm coronary artery aneurysm arising from the right coronary artery.
Coronary fistula
This occurs when a connection between a coronary artery and cardiac chamber or great vessels. It can result in
large coronary artery aneurysms.
Inter-arterial left main coronary artery
This variant is the most significant and likely to cause symptoms. It is often repaired even if not symptomatic,
but always repaired if symptomatic as there is an associated with a significant risk of sudden cardiac death.
Anomalous right coronary artery arising from the left coronary cusp
This variant is rarely symptomatic and is usually only repaired if symptomatic.
A pleural effusion is excess fluid that accumulates in the pleural cavity, the fluid filled space that is situated
between the parietal and visceral pleura. The pleural cavity usually contains between 5-10 ml of this lubricating
fluid. This fluid lubricates the surfaces of the pleurae, allowing them to slide over each other. It also produces a
surface tension that pulls the two membranes together and ensures that as the thorax expands, the lungs do
also and fill with air. Excess fluid in the pleural cavity impairs breathing by limiting expansion of the lungs.
Percutaneous pleural aspiration is generally carried out for two main indications:
The British Thoracic Society (BTS) guidelines suggest that pleural aspiration should be reserved for the
investigation of unilateral exudative pleural effusions. It should not be carried out if unilateral or bilateral
transudative effusion is suspected, unless there are atypical features or failure of response to therapy. It can
also be used for the urgent decompression of the pleural space for the relief of respiratory distress caused by
pleural effusion.
The procedure is usually carried out with the patient sat upright with a pillow nused to support their arms and
head. The patient should not lean forwards too much as it increases the risk of injury to the liver and spleen.
The conventional site for aspiration is posteriorly in the mid-scapular line (approximately 10 cm lateral to the
spine), one or two spaces below the upper level of the fluid. The needle should be inserted just above the upper
border of the chosen rib to avoid the intercostal nerves and vessels that run immediately below the ri
In an ideal world every trainee radiologist would have all the intricacies of staging for all tumour types
committed to memory. A qualified subspecialist radiologist could reasonably be expected to be extreFibrotic
lung disease:
A 65-year-old lady is diagnosed with a fibrotic lung condition on HRCT. There is subpleural honeycombing,
particularly dominant at both lung bases, becoming less prominent superiorly.
Which of the following is the most likely diagnosis?
IPF 82%
NSIP 10%
RBILD 2%
Sarcoidosis 3%
LIP 3%
Explanation:
There is much overlap between NSIP and IPF but gross trends can be seen which help point towards either
diagnosis. Although honeycombing is the go-to feature for IPF, a microcystic version is found with NSIP.
IPF NSIP
Macrocystic honeycombing ↔ GGO
Apicobasilar gradient ↔ Peripheral
Traction bronchiectasis ↔ No nodules
No smoking
Smoking association ↔
association
Architectural distortion ↔ Less distortion
Slightly older ↔ Slightly younger
No response with steroids ↔ Responds to steroids
IPF (Idiopathic pulmonary fibrosis) can only be diagnosed in the absence of a precipitating condition such as
asbestosis, rheumatoid arthritis, or drug toxicity. Where such exists, the condition is termed UIP (Usual
interstitial pneumonia). CFA (Crytpogenic fibrosing alveolitis) is a historic term for the same thing.
There is much overlap in the features of the various different fibrotic lung diseases.
Therefore, look for specific features which are most strongly associated with the different conditions. The table
below (despite appearances) simplifies the overall situation significantly and is inadequate for real life radiology
but does provide a framework on which to build further understanding of these conditions.
The features in bold are the most prominent in each of the conditions.
Diagnosis Feature
COP = BOOP Patchy. Associated with connective tissue diseases, CF, methotrexate, post-transplant
LIP Diffuse pattern, associated with Sjogrens, autoimmune conditions, Hep B, EBV, PCP
A more detailed description of each condition is listed here with those associated with smoking listed first.
There are demographic traits to most of these conditions however for the sake of simplicity these have not been
included here.
Associated with:
Ground glass opacification • Collagen vasculitides
(GGO) (CREST, -myositis,
NSIP Peripheral No sjogrens, RA)
Microcystic honeycombing
• Drugs - chemotherapy
• HIV
Preceded by flu-like
illness
Patchy appearance
GGO Peripheral, Associated with:
COP peribronchial.
Consolidation No • Connective tissue
= BOOP disease
Basal
Reverse halo appearance • Cystic fibrosis
• Drugs - methotrexate
• Post-transplant
Associated with:
• Sjogrens
GGO and centrilobular • AIDS
LIP Diffuse No
nodules • Autoimmune conditions
• Infections (PCP, Hep
B, EBV)
y familiar with the staging for cancers within their remit but for the majority of trainees it is simply not practical to
memorise each and every staging scheme. As an overall strategy, the most important stages to understand are
those which change the management for patients. The patient in this scenario is stage IIIa and thus potentially
curable with an aggressive management plan. At Stage IIIb the management changes significantly because
stage IIIb and stage IV patients are unresectable. Other facts relating to lung cancer (TNM staging) that are
useful to know are those regarding satellite nodules:
o Same lobe = T3
o Different lobe = T4
o Contralateral lung = M1
Post-operative radiotherapy should be offered to the following patient groups:
• T1-3
• N1-2
• (Stage II/III)
For lung cancer some of the important staging features are as follows:
T2 tumours are >3cm but >2cm from the carina N2 = ipsilateral mediastinal or subcarinal nodes
• Chest wall
• Pleura or pericardium
• <2cm of the carina
• Satellite nodules within the same lobe
M1 = bilateral lesions, malignant pleural effusion,
distant metastases
Beyond TNM staging patients with similar prognostic outcomes are given further stages. Simple observation of
these groupings reveals the following:
A 40-year-old man attends A+E with abdominal pain and is diagnosed with pancreatitis. He deteriorates rapidly,
is intubated and ventilated and is admitted to the Intensive Care Unit. There his respiratory failure worsens
although the capillary wedge pressure is normal. He undergoes a CT scan on day 2 of admission which is
reported as showing Acute Respiratory Distress Syndrome.
Explanation:
ARDS is a severe life threatening entity that accelerates rapidly. Patients develop rapidly progressive dyspnoea,
tachypnoea and hypoxia. As the alveoli fill with fluid and debris an arteriovenous (right-to-left) shunt develops
since although the lungs may be well perfused, the under-aeration of the alveoli prevents gas exchange. Despite
oxygenation therefore, the hypoxia becomes refractory to oxygen therapy as oxygenation can only improve a
situation where the patient is ventilating adequately.
Causes of ARDS (Mnemonic - DICTIONARIES)
• DIC
• I nfection
• Caught drowning
• Trauma
• I nhalants (smoke, NO )
2
• Oxygen toxicity
• Narcotics / drugs
• Aspiration
• Radiation
• I ncludes pancreatitis
• Emboli (fat, fluid)
• Shock (septic, cardiogenic, anaphylactic, haemorrhagic)
The chest x-ray may be normal initially but descends into patchy opacification and which becomes confluent
and extensive within hours, involving most if not all of both hemithoraces. On a CT scan there is usually
extensive ground glass opacification and dependant consolidation. The presence of non-dependant
consolidation should raise the possibility of superadded infection at any stage of the course of the disease.
Collagen deposition and fibrosis, often with Non dependant consolidation (suggesting
7-14 days infection)
superadded infection
Subpleural reticulation and honeycombing
(sequelae of developing fibrosis)
If patients do survive they are initially often left with fibrotic changes in the lungs but many patients actually
experience surprisingly few long-term sequelae. The lungs gradually remodel and resolve the fibrotic changes
that take place in the intermediate term.
The wedge capillary pressure is measured via a Swan-Ganz catheter inserted peripherally and fed through the
right side of the heart to reach a branch of the (usually left) pulmonary artery. A small balloon can be inflated to
temporarily occlude this artery and a tiny transducer at the tip of the catheter measures the pressure as the
balloon deflates (the mechanism is similar to blood pressure recording via an upper arm cuff).
Wedge capillary pressure is a surrogate measure for left atrial pressures which rise with left ventricular failure or
problems with the aortic and mitral valves. If the capillary wedge pressure is elevated then a cardiac cause
should be strongly suspected. Non-cardiogenic causes of ARDS should not elevate the capillary wedge
pressure.
What is the most likely description of the nodules that have been seen as part of this condition?
Explanation:
Lung nodules seen on CT take one of three different patterns:
1. Perilymphatic nodules
Peribronchiolar, perivascular, subpleural and close to the fissures
2. Centrilobular nodules
Found in the centre of the secondary pulmonary lobule, with subpleural sparing
Which of the following structures passes through the diaphragm at the vertebral level of T10? Select ONE
answer only.
Explanation:
The diaphragm has three main openings:
• The caval opening: passes through the central tendon
• The oesophageal hiatus: situated in the posterior part of the diaphragm, to the left of the central tendon through
the muscular sling of the right crus
• The aortic hiatus: situated in the posterior part of the diaphragm, between the left and right crus
The main openings in the diaphragm and their contents are shown in the table below:
Explanation:
Lymphangioleiomyomatosis (LAM) is associated with mediastinal lymph node enlargement but is not a usual
differential diagnosis for bilateral hilar lymph node enlargement. The main differential diagnoses would be:
• Malignancy
o Tuberculosis
o Histoplasmosis
o Mycoplasma
• Silicosis
• Sarcoidosis
Lymphangioleiomyomatosis (LAM)
LAM can go misdiagnosed for many years as emphysema. It occurs exclusively in non-smoking women of
childbearing age, unlike this patient, and quite often a history of spontaneous pneumothorax is given.
Radiologically there are numerous small cystic spaces surrounded by normal lung. A chylous pleural effusion
(negative Hounsfield units) is reasonably specific. The main differential diagnosis would be histiocytosis which
tends to be associated with smoking, classically spares the costophrenic angles and gives small nodules but
both can present with spontaneous pneumothorax and give small cysts. The lung volumes in LAM will remain
normal whereas they can be increased in Histiocytosis (surprisingly for a fibrotic lung disease).
Score 1 of 1
Pulmonary hamartoma:
A 7mm peripherally lesion suspected to be a pulmonary hamartoma is being reviewed in the lung MDT.
Explanation:
Fat within a thoracic mass is diagnostic of a hamartoma but is only seen in approximately half of cases. In
contradistinction to carcinoid tumours, hamartomas tend to be peripherally located whereas carcinoid tumours
are often more central. Exceptions to both are reasonably frequent however. Calcification, especially popcorn
calcification, is also very classical for hamartomas if present. Cavitation is not a feature often associated with
them, but it can be found occasionally. Hamartomas are very similar to the chondromas which form part of the
Carney triad (pulmonary chondromas, gastric leiomyosarcomas and extra-adrenal paragangliomas). NB this is
different from Carney syndrome (atrial myxoma, facial/buccal pigmentation, sertoli tumours of the testis and
multiple other findings).
Score 0 of 1
EVAR:
Which of the following features if noted on a CT abdominal angiogram is most likely to render an abdominal
aortic aneurysm unsuitable for endovascular repair?
Explanation:
For the most part it will be the vascular surgeons or interventional radiologists themselves who decide on a
case-by-case basis whether they themselves are prepared to attempt endovascular repair of a given aneurysm.
Broadly speaking however, there are a number of criteria which the surgeon or interventionalist would be wise
to abide by:
• Distance to the renal arteries – 10mm used to be the absolute minimum landing zone distance required but
many of the grafts would required a minimum of 15mm. If the landing zone is less than 10mm a fenestrated
graft must be used to preserve the patency of the renal arteries.
• Angle of the neck – this is measured one of two ways in the literature. Consequently there are two different
values for an acceptable angle. A purely straight aneurysm would have a neck angle of either 180 or 0 in each
o o
of the different measuring systems. Thus the acceptable neck cut-off values are 120 or 60 in each case.
o o
• Angle of the common iliac artery – fortunately this is easier to remember. Iliac arteries at 90 or worse are
o
significantly harder to stent. Further consideration is usually given to the overall tortuosity of the iliac arteries but
this relates to endovascular access as opposed to stent deployment.
• Common iliac artery (CIA) length – Ideally the CIA should be longer than 20mm to accommodate the stents
used. Shorter lengths may require landing in the external iliac artery with deliberate occlusion of the internal iliac
artery and reliance on pelvic collaterals.
• Common iliac artery diameter – Stents are difficult to place where the diameter of the CIA is less than 7mm.
A 28-year-old man undergoes an HRCT after complaints of chronic cough and phlegm production. He is known
to be a user of recreational drugs.
Explanation:
Please note that the question asks which finding is NOT likely to be found.
There are a number of ways in which recreational drug use can affect the patient and be seen radiologically.
• Talcosis - embolisation of particulate matter injected intravenously gives rise to centrilobular micronodules
which may be high density.
• Septic emboli - secondary to non-sterile intravenous injection and endocardial vegetations. Cavitating lung
nodules associated with clinical manifestations of infection.
• Apical bullae/pneumothorax - associated with inhalational drugs, cannabis, cocaine, ecstasy, amphetamines
• Pulmonary oedema - Perihilar airspace opacification with or without pleural effusions. Associated with cocaine,
heroin, methamphetamine use.
• Consolidation - straightforward lower respiratory tract infection secondary to atypical lifestyle, concurrent
immunosuppression, or aspiration during periods of reduced consciousness.
• Nasal septum destruction - associated with snorting cocaine, due to vasoconstriction and necrosis.
• Skin abscesses and pseudoaneurysm - formation at injection sites
64-year-old man with known rheumatoid arthritis develops respiratory symptoms. He undergoes an HRCT.
In which region would you most expect there to be radiological changes?
Centrally 1%
No zonal predilection 3%
Peripherally 7%
Explanation:
Involvement of either the upper or lower zones is typical for a number of different pathologies. Many of the
upper lobe pathologies related to inhalational processes and conversely many of the lower lobe pathologies can
be explained by their basis in the increased blood flow. There are a number of different mnemonics for either
area, some better than others.
R = Radiation
A = Ankylosing spondylitis
S = Sarcoidosis
T = Tuberculosis
S = Silicosis
Involvement of the lower zones can be remembered with the mnemonic BADAS:
B = Bronchiectasis
A = Aspiration pneumonia
Explanation:
Approximate statistics
Pneumothorax of any size 25%
Haemoptysis 3%
• Severe COPD
• Pulmonary hypertension
• Coagulopathy
o PLT <50
o INR <1.4
• Contralateral pneumonectomy
• (echinococcal cysts)
A mycotic aneurysm occurs when the integrity of the wall of the aorta is compromised by bacterial infection,
usually spread from a source elsewhere within the body either haematogenously or by local spread. These
aneurysms tend to be more saccular or multilobulated in morphology, reflecting the focal mural compromise.
Adjacent soft tissue stranding is present and adjacent gas locules are almost pathognomonic, albeit rare.
An aortic aneurysm is simply a dilatation of the aorta. The vast majority of these will be degenerate, caused by
longstanding atherosclerosis and hypertension. Connective tissue diseases such as Marfan syndrome or Ehlers-
Danlos can predispose to aortic aneurysms at an earlier age. Fusiform aneurysmal dilatation is typical of a
degenerate aneurysm.
Pseudoaneurysm formation occurs when there is rupture through one or more of the layers of an artery but
there is containment of the rupture either by the adventitial layer or surrounding soft tissues. They are commonly
either traumatic or iatrogenic in aetiology. Mycotic aneurysms can become pseudoaenurysmal.
A 68-year-old man undergoing chemotherapy for leukaemia has a CT scan. This shows nodular region with a
crescent of air in the left upper lobe which was not there three weeks previously.
Explanation:
How the fungus aspergillus affects a patient depends on their underlying immune status.
Invasive aspergillosis
Invasive aspergillosis is one of the ways in which the fungus aspergillus can affect the lungs. It occurs only in
patients with a severely compromised immune system such as those with AIDs, on high dose steroids or (like
the patient in the question) neutropenic. There is endobronchial fungal growth with vascular invasion leading to
microthrombois and microinfarction. This is seen initially as a characteristic halo sign which over the ensuing
two weeks undergoes necrosis and cavitation developing as it does so, an air crescent sign. Although this is a
different process to the creation of a Monod sign (air crescent at the superior aspect of an aspergilloma) they
can seem similar.
ABPA
ABPA causes a ‘migratory pneumonitis’, typically affecting the upper lobes. Parenchymal changes are fleeting;
appearing in one area of the lung one week and a different area the next. The ‘finger in glove’ sign can often be
seen, where mucus plugging of a bronchus allows the distal airway to fill with secretions giving rise to a ‘V’ or Y’
shaped shadow on a CXR or CT. This is known as a finger in glove sign owing to its appearance. Central
bronchiectasis is a prominent feature and is can be given in an exam question setting as ‘ring shadows’ on a
CXR. The peripheral bronchi are classically spared. Cavity formation is seen in the later stages of the disease
although aspergillomas are not typical (these occur in patients with a normal immune system). The typical
patient in an exam question setting will be young, with a history of either asthma or cystic fibrosis or ‘chronic
lung disease’, symptoms of malaise, headache and intermittent chest pains, and an eosinophilia on their full
blood count.
Score 1 of 1
Thoracic dissection:
You are on duty and called by a cardiothoracic surgeon to discuss a 45-year-old man with Marfan syndrome,
and known anaphylaxis to iodine, who presented with intense chest pain. His oxygen saturation is 95% on room
air, heart rate is 86 beats per minute and blood pressure is 154/98mmHg. The surgeon suspects he may have
an aortic dissection.
What should you advise next before the patient is taken to theatre?
CT thoracic angiogram 3%
Nothing 8%
CXR 13%
MR angiogram 54%
Explanation:
This patient is haemodynamically stable. In the absence of a confirmed diagnosis, a CT angiogram should be
performed. Depending on local availability, MR angiography can be a useful adjunct to CT for patients who are
allergic to iodinated contrast although clearly the patient must be sufficiently stable to undergo an MRI scan.
In a haemodynamically stable patient for whom the diagnosis was in doubt the correct study to perform would
be a cardiac-gated CT aortogram:
• Unenhanced CT thorax - This phase is important in the diagnosis of an intramural haematoma which can be
difficult to pinpoint on subsequent phases.
• Arterial phase CT Thorax and Abdomen - It is important to know whether a dissection extends into the
abdominal aorta or iliac arteries as well as whether there is any compromise of the mesenteric or renal arteries.
• (Portal venous phase CT Thorax and Abdomen - This phase is not always performed but is most useful if
previous repairs have been undertaken and a leak is suspected)
Although not universally available, cardiac-gating of CT scans for acute aortic syndrome is optimal to reduce the
rate of false positives which are a well-documented pit-fall to non-gated studies.
Depending on local availability, MR angiography can be a useful adjunct to CT for patients who are allergic to
iodinated contrast although clearly the patient must be sufficiently stable to undergo an MRI scan.
Score 0 of 1
PR bleeding:
A 76-year-old man presents with fresh blood PR. He requires a transfusion of 4 units due to the volume of blood
lost and investigations are underway to establish the source of the bleeding. He undergoes a catheter
angiogram.
Which vessel should be targeted first in the search for the source of the bleeding?
Answer Option Question Statistics
Coeliac axis 2%
IMA 78%
Gastroduodenal artery 4%
SMA 10%
Explanation:
Fresh PR bleeding is most likely to be colonic. When performing a mesenteric angiogram it is wise to begin with
the IMA since once contrast begins to be excreted renally, the filling of the bladder may obscure more inferiorly
placed bowel loops.
The gastroduodenal artery arises from the common hepatic artery, a main branch of the celiac axis. The
Marginal artery of Drummond completes an anastomotic loop connecting the SMA, via the middle colic artery,
and the IMA.
CT chest changes:
A 37-year-old woman with progressive dyspnoea and cough over the last 20 months is being investigated. She
has never smoked and has a history of recurrent pneumathoraces. Her CT chest shows a coarse reticulonodular
interstitial pattern with multiple cysts in both lungs.
Neurofibromatosis 1%
Lymphangioleiomyomatosis 82%
Explanation:
Lymphangioleiomyomatosis (LAM)
This is the classic description of LAM. LAM can go misdiagnosed for many years as emphysema. It occurs
exclusively in non-smoking women of childbearing age, and quite often a history of spontaneous pneumothorax
is given. Radiologically there are numerous small cystic spaces surrounded by normal lung. A chylous pleural
effusion (negative Hounsfield units) is reasonably specific. The main differential diagnosis would be histiocytosis
which tends to be associated with smoking, classically spares the costophrenic angles and gives small nodules
but both can present with spontaneous pneumothorax and give small cysts. The lung volumes in LAM will
remain normal whereas they can be increased in Histiocytosis (surprisingly for a fibrotic lung disease).
Histiocytosis (also known as Langerhans cell histiocytosis - LCH)
There are three separate forms of this disease:
1. Eosinophilic granuloma (70%) – a limited version confined to the skeleton in children or young adults. Clinically
presents as fever, raised WCC and ESR with painful bony lesions. In the skull these have a typical ‘beveled
edge’ or ‘hole within a hole’ appearance or can be seen as a ‘button sequestrum’. In the spine it is one of the
main causes of vertebra plana.
2. Hand-Schüller-Christian Disease (20%) – classically a triad of destructive bony lesions, diabetes insipidus and
exophthalmos. In a quarter of these patients the lungs are involved with cyst formation and spontaneous
pneumothoraces possible. Nodule formation, fibrosis and honeycombing is also seen.
3. Letterer-Siwe Disease (10%) – a fulminant multi-organ variant affecting very young infants
There is a strong association with smoking for patients who develop pulmonary features of LCH. Heavy
smoking causes an accumulation of Langerhans cells and hence, as with other inspiration-related lung
diseases, there is a predilection for the upper zones. The Langerhans cells can collect with other cells and
become small granulomas seen as small lung nodules. Despite being a type of fibrotic lung disease the lung
volumes can be increased. Small lung cysts form and there is a risk of spontaneous pneumothorax. There is
usually sparing of the costophrenic angles which can be a key finding.
Neurofibromatosis
Technically neurofibromatosis (type I) is included in the differential diagnosis for lung cysts (particularly when
apical) however the rest of the information provided is insufficient to make this the most likely answer here.
Score 1 of 1
Tree-in-bud:
An HRCT performed on an outpatient shows a classic tree-in-bud pattern peripherally in the middle lobe.
Aspergillosis 10%
Diffuse panbronchiolitis 6%
MAC 68%
CMV infection 8%
Cystic fibrosis 9%
Explanation:
A tree-in-bud pattern occurs when the lumen of the terminal bronchiole is filled with radiopaque material.
Historically the appearance was associated most strongly with tuberculosis however it is more recently
recognized as a feature common to many different pathologies. The nature of the material depends on the
underlying pathology. For instance:
Here we are given the term tree-in-bud but this can also be indicated with a visual description of this entity such
as ‘small centrilobular nodules connected by branching opacities’ or words to that effect.
MAC – mycobacterium avium complex
This is an atypical mycobacterial infection is often seen in the form of Lady Windermere syndrome. Classically
there is bronchiectasis and tree-in-bud in the right middle lobe which is affected in isolation from the rest of the
lung and the patient is usually an otherwise perfectly healthy Caucasian elderly woman. Lady Windermere is the
central character in a play by Oscar Wilde. The play was written in an era where it would have been considered
impolite and unpleasant to cough. The term applies to a form of MAC infection thought to result from voluntary
suppression of the kind of cough which would usually be expected with the airway irritation brought on a
pathogen. Where MAC occurs in not otherwise healthy individuals there is an association with any disease
causing bronchiectasis.
Cystic fibrosis
Lung changes in cystic fibrosis affect all lobes of the lung.
The problems caused by this autosomal recessive condition have their origins in a two separate processes.
Firstly exocrine gland dysfunction causes the usual mucus secretions of the lungs to be far more viscous than
normal and thus harder to clear. Secondly ciliary dyskinesia means that this thick mucus is poorly cleared. The
combination of both processes results in stasis of mucus in the lumen of the broncho-alveolar tree (giving rise
to the tree-in-bud appearance) and this then becomes a breeding ground for various infections, with
subsequent bronchiectasis.
Diffuse panbronchiolitis
This is an idiopathic condition where there is progressive inflammation of the small airways in, as the name
implies, a diffuse pattern. The classic patient demographic is a middle-aged non-smoker of Asian heritage.
Aspergillosis
Of the different varieties of pulmonary aspergillosis it is allergic bronchopulmonary aspergillosis (ABPA) which is
most associated with the tree-in-bud appearance. This occurs due to hypersensitivity towards aspergillus
spp and is seen in asthmatics or, less commonly, patients with cystic fibrosis. Hypersensitivity reactions give
rise to bronchial wall oedema and the broncho-alveolar lumen becomes filled with fluid. Superimposed mucous
impaction is also a feature. Owing to the inhalational element of pathogen exposure there is a predisposition for
the upper lobes.
CMV infection
An opportunistic infection, CMV is seen in immunocompromised patients, most commonly those with AIDs. As
a cause of the tree-in-bud appearance it is unusual because the luminal opacification is derived from bronchial
wall thickening as opposed to an exogenous substance. Changes are usually widespread; there is no particular
predilection for the middle lobe.
Sagittal reformatted CT image showing "tree in bud" appearance of impacted distal small airways in primary
ciliary dyskinesia.
Which of the following is a complication of this procedure? Select ONE answer only.
Asherman syndrome 7%
Meig syndrome 2%
Endometrioma 3%
Dermoid formation 0%
Explanation:
Asherman syndrome
Historically this condition was the result of infection with tuberculosis but nowadays it is more often the
consequence of iatrogenic endometrial damage. The formation of intrauterine synechiae leads to subfertility and
these fibrous bands can be seen on HSG as filling defects and surface irregularity. Asherman syndrome should
not occur following uterine artery embolisation.
In the world of interventional radiology, uterine fibroid embolisation is gaining momentum. The uterine artery
arises from the internal iliac artery whereas the ovarian artery arises directly from the aorta and has a corkscrew
appearance on angiography. Anastomoses between the two arteries or the two sides exist in approximately
20% of patients. Patients should be counselled for the risk of ovarian dysfunction subsequent to the procedure
and patients over the age of 45 are at particular risk. Pedunculated fibroids are said to be poor candidates for
embolisation owing to their propensity to detach however the literature is slightly contradictory on this topic.
Following a successful embolisation the fibroid should undergo infarction and involution. On an MRI scan there
will be high T1 signal with low T2 signal and no enhancement of the infarcted tissue post-contrast.
Complications include:
Asherman syndrome
Historically this condition was the result of infection with tuberculosis but nowadays it is more often the
consequence of iatrogenic endometrial damage. The formation of intrauterine synechiae leads to subfertility and
these fibrous bands can be seen on HSG as filling defects and surface irregularity. Asherman syndrome should
not occur following uterine artery embolisation.
Meig syndrome
This is a triad of an ovarian fibroma (usually, other ovarian tumours do cause it too), ascites and pleural
effusions. A right sided pleural effusion is more common than the left. The underlying mechanism is unclear.
Two possible explanations are that either the tumour irritates the peritoneum leading to a build-up of
inflammatory fluid, or that histamine release alongside other chemicals and hormones causes vasodilation and
fluid exudation that way.
Score 0 of 1
Silicosis:
A 53-year-old man with chronic dyspnoea has a CT scan which shows biapical volume loss with reticulonodular
changes in both upper lobes. There are tiny opacities with a density greater than that of soft tissue and eggshell
calcification of mediastinal lymph nodes.
Pleural thickening 65
Intralobular reticulations 12
Dense nodules 9%
Explanation:
Silicosis
Inhalation of silica leads to fibrosis. It is an occupational hazard associated with working in mines, quarries or
with glass and ceramics. Chronic silicosis occurs following exposure over 10-20 years. Small nodules
measuring a few millimeters in diameter form with an upper zone distribution (involvement of the upper zones is
classical for inhalational diseases). Around 10% of these nodules calcify and this can be seen on imaging as
multiple small foci of calcification in the upper zones. Lymph node enlargement is also a feature with eggshell
calcification often quoted as a dominant feature of silicosis despite only being present in around 5% of patients.
Intralobular septal thickening is often seen but pleural involvement is not a feature of silicosis.
Fibrosis by location:
You are reviewing a chest x-ray which shows upper zone fibrosis.
Asbestosis 75%
Silicosis 3%
Ankylosing spondylitis 7%
Explanation:
Involvement of either the upper or lower zones is typical for a number of different pathologies. Many of the
upper lobe pathologies related to inhalational processes and conversely many of the lower lobe pathologies can
be explained by their basis in the increased blood flow. There are a number of different mnemonics for either
area, some better than others.
A = Ankylosing spondylitis
S = Sarcoidosis
T = Tuberculosis
S = Silicosis
Involvement of the lower zones can be remembered with the mnemonic BADAS:
B = Bronchiectasis
A = Aspiration pneumonia
D = Drugs and Desquamative interstitial pneumonia
A = Asbestosis
Lymphangitis carcinomatosis is easy to recognize on a scan but can be described in a number of different ways
on paper. It occurs when tumour cells, spread via the lymphatics, accumulate in the connective tissues of the
lung, in particular the interlobular septa. The classical description is as a smooth thick reticular polygonal
network.
A mnemonic for the likely cancers is: Certain Cancers Spread By Plugging The Lymphatics (this is not an
exclusive list). Of these Breast accounts for just over half of cases and gastric cancer accounts for most of the
remainder.
• Cervix
• Colon
• Stomach
• Breast
• Pancreas
• Thyroid
• Larynx (or lung – bronchogenic)
Score 1 of 1
Cavitating lung lesions:
A 78-year-old woman undergoes an outpatient pacemaker insertion for cardiac arrhythmia. Following an
uneventful operation she is re-admitted 10 days later with severe shortness of breath. She undergoes a CT scan
which shows cavitating lung nodules and a wedged shaped liver lesion.
Under anticoagulation 9%
Metastatic HCC 1%
Primary tuberculosis 0%
Explanation:
The history of a recent cardiological intervention together with the liver pathology suggest this to be the most
likely diagnosis. If a lesion has a ‘wedge’ shape, this strongly suggests a vascular origin such as an embolus or
infarction. Although none has been given here, a suggestion of systemic sepsis would further solidify the
diagnosis.
T = Trauma – pneumatocoeles
Y = Youth (ie congenital – CPAM, sequestration, bronchogenic cyst) These all form cysts, not true cavities as
such.
Under anticoagulation leading to embolus formation could occur but would not classically affect the liver.
Metastatic HCC – HCC usually metastasizes late in the disease. They can present either as solitary lesions,
multiple lesions or as an infiltrative area but none of these would usually be described as wedge-shaped.
Metastatic lung cancer – a lung nodule is technically smaller than 3cm in diameter (this would be T1 in the TNM
classification of non-small cell lung cancers) and bronchogenic SCCs tend to be larger than this when they do
metastasize. Liver metastases would not usually be conform to the description of ‘wedge-shaped’.
Primary tuberculosis does not usually cavitate but by contrast cavitation can be seen in anything upto two fifths
of post-primary tuberculosis cases.
Score 1 of 1
CXR findings:
You are reviewing a CXR with a left upper lobe collapse on it.
Explanation:
The silhouette (pronounced as: sil-o-wet) sign has a leading role in the interpretation of chest xrays. It occurs
when two structures are adjacent to one another and it is therefore not possible to see where one begins and
the other ends on a CXR. In order to see all the way around any structure it must have a difference in density
between it and any structure touching it; this is called ‘contrast’. The silhouette sign is useful because it can be
used to define the anatomical location of pathology.
Lobar collapse
Lobe Silhouette sign CXR finding
Veil-like opacification over upper and middle
Left upper lobe Aortic knuckle zones, Luftsichel sign
Hyperlucent lung:
What is the most common cause of an incidental hyperlucent left lung on a PA chest radiograph of a 30-year-
old woman?
Swyer-James syndrome 6%
Alpha-1-antitrypsin 1%
Explanation:
Film rotation
Unfortunately it is more likely that technical features will cause unilateral hyperlucency than any of the
pathological conditions which may feature in the differential diagnosis. Rotation of the patient to the left on a PA
film will bring the left hemithorax away from the plate. The chest anatomy is such that in doing so the xray beam
travels through less lung tissue in terms of depth than either the contralateral side in the same rotated patient or
the left lung in an unrotated patient. The beam travelling through less lung tissue is therefore less attenuated
and the lung appears hyperlucent on the resultant film
Poland syndrome
Poland syndrome is a rare cause of a hyperlucent hemithorax on a CXR. There is hypoplasia or even aplasia of
the chest wall musculature plus/minus breast. Abnormalities of the fingers on the same side such as syndactyly
(fusion) or brachydactyly (shortening) can also occur and the ipsilateral ribs may also be abnormal.
Swyer-James syndrome
In this condition, normal development of the infant lung is impeded by bronchiolitis (viral or mycoplasma) at an
early age, with superadded acute airspace destruction. Consequently the affected lobe is small and lucent on
the CXR due to air trapping. It is a differential diagnosis for a unilateral lucent hemithorax, along with a
pneumothorax, very large pulmonary emboli and causes of decreased chest wall musculature such as Poland
syndrome or, historically, polio. In an an exam situation Swyer-James syndrome is usually given as a teenage or
young adult patient with a history of recurrent LRTIs. Air trapping, and bronchiectasis can also be described.
Eggshell calcification:
Which of the following is NOT a cause of eggshell calcification of thoracic lymph nodes?
Tuberculosis 12%
Asbestosis 64%
Talcosis 13%
Sarcoidosis 5%
Explanation:
Eggshell calcification
When the outer rim of a lymph node becomes calcified it is seen on CT as eggshell calcification. There is a
relatively specific differential diagnosis for diseases which can manifest in this way.
• Fibrosing mediastinitis
• Amyloidosis
• Pneumoconioses - silicosis and coal workers only. Not seen in most others.
• Sarcoidosis
• Scleroderma
• Treated lymphoma (ie post radiotherapy)
• TB
• Histoplasmosis
Aortic dissection:
A 47-year-old man experiences sudden onset chest pain and is being investigated for a myocardial infarction.
On examination, the A+E doctor notices he is unusually tall with pectus excavatum deformity and long fingers.
An early diastolic murmur is heard on auscultation. He undergoes a CT scan and is found to have an aortic
dissection.
Aortic root 7
Explanation:
The patient has Marfan syndrome which is an autosomal dominant connective tissue disease. Among other
common features associated with this condition, the patient in this scenario is tall, with arachnodactyly and
pectus excavatum. An early diastolic murmur suggests regurgitation, usually of the aortic valve but less
commonly the pulmonary valve. Aortic regurgitation is another feature common to Marfan syndrome but
although this may be present it would not necessarily explain his sudden chest pain. Patients with Marfan
syndrome are at increased risk of developing aortic dissection compared to the general population.
Dissections are classified according to their involvement of the aortic root and their distal extent. There are two
different classification systems. The Stanford classification is more useful clinically since the primary decision
post-diagnosis is whether the dissection will be managed surgically or medically. Those involving the proximal
aorta and arch are managed surgically. If the arch is not involved, the patient can be managed medically. Thus
Stanford A dissections involve the aorta proximal to the origin of the left subclavian artery with or without
concurrent distal involvement. Stanford B dissections do not involve the proximal aorta.
Most dissections originate just distal to the aortic valve and extend proximally, ie Stanford type A.
Traumatic aortic rupture is most likely to occur at the site of the ligamentum arteriosus, just distal to the origin of
the left subclavian artery. This is termed the aortic isthmus. The proximal aorta is fixed by the ligamentum
arteriosus but distal to this point the aorta is more freely mobile.
Coarctation of the aorta is associated with a late systolic or continuous systolic murmur.
Pectus Excavatum:
Image sourced from Wikipedia(link is external)
Courtesy of Bakalli et al. CC BY-SA 3.0(link is external)
Classification: