Chest X Ray

Bilateral consolidations
● Patchy and peripheral
No pleural effusion

Covid-19 pneumonia

Peripheral distribution rather than perihilar

Increased consolidation in R lower zone

Consolidation is in the middle lobe

Structures next to each other

R heart border is seen clearly - R middle

lobe is clear
R hemidiaphragm is gone - R lower lobe
pneumonia
Causes: Left upper zone collapse

Increased opacification in L upper zone

Outline of aortic arch and L heart border is
not clear - bordered by left upper lobe

Diaphragm is tented upwards - volume loss

Veil sign

Divided by oblique fissure

When LUL collapses - it collapses upwards
Left: abnormal thickening of R paratracheal
strap

Horizontal fissure is gone as it has been

pulled upwards

Triangular density behind the heart

L: faint opacity next to R heart border

- Right rib fractures
R rib fractures
Hard to spot on the AP x ray

Look for complications

Pneumothorax
Lung contusions
Flail chest

Thymus present in mediastinum - normal

Right lung looks bigger

R border of heart and hemidiaphragm looks
very sharp - something increasing the
contrast (air)

Free air - lateral decubitus x ray

R pneumothorax
Air rises in an erect film
Air moves anteriorly in a supine x ray

Left PTX

There is a right PTX but has chest drain in

situ (chest drain has no kinks)
 Widened mediastinum
R hilum angle is gone

Aorta does not look unfolded, young patient

Mediastinal mass

● Mediastinal mass - forms obtuse angle with mediastinum

● Pulmonary mass - forms acute angle with mediastinum
Elderly patient with chest pain
Widened mediastinum
Aorta unfolded

R: previous radiograph

Calcifications are displaced medially from

the outer wall of the aorta - intima
calcifications and outer wall - aortic
dissection/intramural hematoma
Wall of aorta - grossly thickened
Calcifications have been pushed inwards

Type A intramural hematoma - requires

surgical intervention

Widened mediastinum
Not arising from the aorta or the heart - can
see the borders clearly
Esophagus → think of this when see the air fluid
level
Esophagus - contiguous with stomach

Dilated esophagus
No GEJ mass

Young patient with dilatation of oesophagus

Abnormal lucency around the heart - air in

the pericardium

Multiple streaky opacities

Soft tissue gas in the supraclavicular
regions - subcutaneous emphysema

Not Psuedomediastinum - when border of

the heart looks abnormally prominent
How would you manage this child?
Oblique for rib fractures
Look out for NAI in paeds
How to differentiate between
pneumopericardium and
pneumomediastinum?
Pneumopericardium - air is only around the
heart
Pneumomediastinum - generic word; might
be along the different fascias in the
mediastinum
Correlate clinically! E.g. if pericardocentesis
was just done then consider
pneumopericardium

Abdominal Imaging
Aka Bowel pneumatosis
Look at the liver for portal venous gas
Gas accumulates in the anterior abdominal Not that impt
wall (Rigler’s sign: gas - bowel wall - gas)
Less sensitive sign to detect free gas
(needs about 1L of gas before appears)
Erect CXR/ erect abdominal x ray to look for
gas

Branching lucencies within the liver - extend

to the periphery of the liver
 Kidneys - running parallel to the psoas
muscles

Centrally located

Key areas
● Renal shadows
● Ureters - trace along path
● Bladder

Faceted - have multiple sides

Easier to see on CT

Chronic pancreatitis - atrophic and calcified

pancreas

Characteristic appearance
Might need CT to differentiate with urinary
calculi, esp if have symptoms of urinary
colic
Lung bases
Groin area

Multiple sclerotic lesions

Female patient - gynecoid pelvis, IUD
inserted inside
?breast mets
Emphysematous pyelonephritis
● Gas in the L kidney - outlining the
staghorn calculus
● Sepsis
‘Dirty’ looking gas

Hepatosplenomegaly 2’ to lymphoma
Small bowel obstruction
● Dilated small bowel loops
● Centrally located
● Valvular conniventes → cross the
entirety of the bowel
● >3cm
● Air fluid levels
○ 2.5cm in length
○ >5
○ Intestinal obstruction
L: surgical clips in the pelvis with small
bowel obstruction (likely adhesion)

R: dilated large bowel loops (peripherally

located with haustration which stop along
the bowel) with air fluid level

Management
● Endoscopic decompression

Sigmoid volvulus
Cecal volvulus
● Tend to be located in RIF instead of
LIF
● Extends superiorly
● Rare

Pneumatosis and portal venous gas

● Gas outlining the ascending colon -
large bowel wall (pneumatosis)
● Liver: faint branching lucencies -
portal venous gas
Portal venous gas Gas in bowel wall

Seen in premature neonates - necrotizing

enterocolitis
● Difficult to distinguish between the
small and large bowel for neonates
● Mottled appearance and branching
lucencies in the liver
● Conservative mx with abx unless
there is perforation
Decubitus view to see the portal venous gas

Rigler’s sign

R side up
Gas accumulates under the skin
Free gas under diaphragm

Pneumoperitoneum from perforated viscus

Gas under R hemidiaphragm

Examples of free gas in a supine radiograph

 Aneurysm

Curvilinear calcifications along the paravertebral region

CT aortogram of this patient
Cecal volvulus often have haustra
appearance but sigmoid calculus has an
absence of haustra.
Top 10 Tips for HOs
Lowest life form in the hospital
CTAP: 10 mins
MRI scan: 30 mins

Pein
Portovenous is the most common phase
Time critical - please call radiologist
 20G pink plug (bare minimum)

US HBS/ abdomen - gallbladder (contracted

if not fasted)

Contrast - ideally antecubital pink plugs at the very least in order to have high enough
contrast speed to visualise organ
 Mild - swelling and pain
Severe - ulceration, necrosis, compartment
syndrome

Large volumes may need to be referred to

plastics for mx

For CT and MRI contrast

Patients CKD on dialysis are NOT suitable

for IV contrast for MRI
MRI contrast does not lead to CIN

NAC is no longer recommended for lowering CIN risk

IV hydration with normal saline can be considered
CT scan contrast allergy has no cross-reactivity with MRI contrast allergy
Not required for CT scan

Implant compatibility is important for MRI

scans
After 4 weeks - fibrosis around implant formed, less risk of migration
Light oral sedation if patient is slightly nervous

Prefer non ionizing - US/MRI

Mum > baby

No adverse effect of IV contrast in pregnancy e.g. in CT PA
MRI contrast is NOT safe in pregnancy
Non-stochastic: only beyond a certain dose
Stochastic: unsure of the dosage