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PAMS 626 orientation

PAMS 626 orientation

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PAMS 626 Essentials of Radiology

Matthew Chanin, M.D.

9/15/08

Objectives
Develop an understanding of imaging modalities Learn radiographic anatomy Identify significant pathology on plain x-rays (radiographs) Appropriately utilize imaging examinations

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Course
Lectures and film interpretation Pop quizzes “Hot” seat approach Mid-term and final- 50/50

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Assumptions
Basic knowledge of anatomy Outside reading
– Squires – Mettler’s- Essentials of Radiology (optional)

Class participation Excellent night vision
– book light
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What is Radiology (Diagnostic Imaging)?
Or why are you here?

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Patient Wellness

Intervention

Imaging

Labs

History and Physical

Patient’s Illness
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Goal of Imaging
Appropriate examinations
– Most effective test to answer the clinical question – Patient able to cooperate with the exam

Least cost Timely Minimize risks
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Imaging Modalities
Plain x-ray (plain film) (radiograph) Ultrasound Computed tomography (CT) Magnetic Resonance Imaging (MRI) Nuclear Medicine

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Plain X-ray (films)
Creates an image using x-rays
– Images captures on film or digitally

Advantages
– Readily available – Less expensive

Disadvantages
– Risk of ionizing radiation – Many studies are insensitive, i.e. abdominal (KUB) films – May delay definitive examination
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X-ray tube

Collimator

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X-ray tube patient

Analog cassettecontains film

Exposed film

Developed film

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Analog film development

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Analog cassette

X-ray tube patient Digital cassette (no film) Laser reader Digital image to PACS workstation Digital copy sent to archive for storage

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Digital film processing and interpretation on a Picture Archiving and Communication System (PACS)

Common Plain Film Exams

Chest Musculoskeletal

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Abdomen

Common Plain Film Indications
Chest
– – – – – – – ? Pneumonia ? Trauma ? Mass ? Trauma ? Arthritis ? Bowel obstruction ? Perforated bowel (free air)

Musculoskeletal

Abdomen

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Risk of Ionizing Radiation
X-rays cause ionizations in living cells Ionizations remove electrons form atoms creating ions Ions interact with and possibly damage DNA Cells can repair some damage Higher x-ray doses can cause cell death or cell mutation (cancer) Dividing cells at greater risk- pregnant patients and children Effects are additive and cumulative over the patients lifetime
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Imaging the Pregnant Patient
No plain films or CT of the abdomen, pelvis, lumbar spine or hips unless clearly medically indicated Order ultrasound or MRI examinations if possible Contact the Radiologist before beginning imaging workup

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Radiation Protection for the Health Care Worker
Time
– Limit time in a radiation producing area

Shielding
– Wear a lead apron

Distance
– Single greatest source of x-ray exposure to the health care worker is scatter radiation from the patient

Radiation monitoring badge may be required
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Contrast Administration
Contrast allows identification of normal structures not normally seen on plain films Contrast also helps identify pathology Intravascular contrast- into blood
– Intravenous pyelogram (IVP) – CT – MRI

Intraluminal contrast- into gut
– – – – Upper Gastrointestinal (UGI) exams Small Bowel Follow through (SBFT) Barium Enema (BE) CT

Patients usually require a prep and pre-procedure labs
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Intravascular Contrast
Tri-iodinated benzene ring 90+ percent renal excretion Complications include
– Allergy – Renal insufficiency/failure
Especially diabetics

– Cardiovascular abnormalities – Potential lactic acidosis in diabetic patients taking Glucophage (Metformin), discontinue before scan and for 48 hours after scan

Patients require pre-procedure BUN, Cr
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Pre-Medication Recommendations
History of “contrast allergy” If prior contrast reaction was severe, i.e. breathing difficulty consider another test and/or consult the radiologist Prednisone, 50 mg PO at 13 hr, 7 hr, and 1 hr before scan Diphenhydramine (Benadryl), 50 mg PO, 1 hr before scan

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MR Contrast
Gadolinium Gadolinium compound accumulates in abnormal tissues such as scar tissue and tumors, so they become brighter in MRI scans Passed out of the body in urine-rarely gadoliniumbased contrast agents can cause acute renal failure in patients with underlying chronic renal insufficiency Reactions are rare but can be life-threatening
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Intra-luminal Contrast
Barium
– Administered orally or per rectum – Different concentrations – Usually well tolerated – Few complications

Water soluble contrast
– Used with suspected perforation

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Abdomen without intravascular contrast

Abdomen with intravascular contrast

Abdomen without Intraluminal contrast

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Abdomen with Intraluminal contrast (UGI)

Ultrasound
Creates an image with sound waves Prep usually required
– NPO for abdominal studies- optimize gallbladder distention – Force fluids (bladder distention) for pelvic ultrasound to aid in organ visualization

Advantages
– – – – – – – NO ionizing radiation Portable and noninvasive (almost) Fast, useful in screening trauma patients Guide interventions- para/thoracentesis Requires a skillful operator Anatomy is complex Patient size can limit study

Disadvantages

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Ultrasound
Images can be recorded on film or sent to a PACS workstation

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Common Ultrasound Exams and Indications
Abdominal (RUQ, renal etc.)
– – – – – – – – – – – – – ? Gallstones or biliary tract disease Evaluate organ size Screen for masses Look for fluid (ascites) ? Hydronephrosis Evaluate aorta for aneurysm ? Ectopic pregnancy Vaginal bleeding ? ovarian pathology ? Torsion Evaluate mass ? Stenosis or occlusion ? Cardiac or valvular function

Pelvic

Testicular Vascular Cardiac-Echocardiography (Cardiology)

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Fetal Ultrasound
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Intracavitary

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Different Ultrasound Transducers

Doppler Ultrasound
Method to evaluate blood flow Usually displayed in color

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Computed Tomography (CT)
Cornerstone of imaging the acute abdomen, trauma and cancer patient Images can be filmed or interpreted on a PACS workstation Advantages
– Displays data in thin sections allowing for multiplanar reconstruction – Fast – Numerous software programs available for data analysis

Disadvantages
– – – – Ionizing radiation-LOTS! Frequently over utilized Many scans require intravascular contrast Unstable patients need close monitoring

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CT Scanner

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Common CT Exams and Indications
Head
– ? Stroke, bleed

Chest
– ? Mass – ? Trauma – ? Pulmonary embolism

Abdomen/Pelvis
– – – ? Appendicitis, renal stone, diverticulitis, bowel obstruction ? Mass ? Trauma

Musculoskeletal
– Characterize fractures
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Abdominal CT without contrast

Abdominal CT with intravascular and intraluminal contrast
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(Axial)

Planes of imaging
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Axial (transaxial)

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Coronal

Sagittal

Examples of CT image multiplanar reformation (MPR)

Advanced CT Techniques
CT angiography (CTA)
– Minimally invasive (requires IV and contrast injection) method to evaluate vascular anatomy/pathology

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Abdominal aortic aneurysm displayed on 3D workstation

Heart

Extremities
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Aorta and kidneys

Examples of CTA

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CT- Virtual Colonoscopy

Radiation Dose Selected Procedures-Compared to Standard Chest X-ray
Examination Chest X-ray CT Abdomen/pelvis BE Ultrasound
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Effective Dose relative to a Chest X-ray 1 (0.1 mSv) 160+ 80 0

Radiation Warning
Controversial but increase in cancer risk is thought to occur with approximately 1,000 chest x-ray equivalent Radiation effects are additive over patients lifetime
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Magnetic Resonance Imaging (MRI)
Creates images with a strong magnetic field and radio waves Images can be filmed or sent to a PACS workstation for reading Advantages
– Superior resolution of soft tissues including brain, spinal cord and joint anatomy – Helps characterize abdominal masses – No ionizing radiation, yet not FDA approved for routine fetal imaging – Multiplanar imaging standard
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MRI
Disadvantages
– Ferromagnetic metals, i.e., aneurysm clips, older heart valves cannot be scanned – Patients with implanted devices, i.e., pacemakers, infusion pumps cannot be scanned – Serious risks to patients if proper safety precautions are not followed – Long scan times – Magnetic bore can induce patient claustrophobia – Loud “banging” noises during image acquisition requires patients to wear ear plugs – Patients with a history of welding or metal grinding may require preMRI orbit films

Most MRI centers have a lengthy pre-MRI check list
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MRI machine
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Common MRI Exams and Indications
Brain
– ? Stroke, mass

Chest
– ? Aortic dissection, vascular abnormality

Abdomen
– ? Mass

Musculoskeletal
– ? Ligamentous injury
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Head coil/sagittal MRI

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Knee coil/sagittal MRI

Advanced MRI Techniques
MR angiography (MRA)
– Noninvasive evaluation of vessels

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MR Spectroscopy
Noninvasive method to determine chemical composition of select tissue

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Nuclear Medicine (NM)
Image different organs by injecting different radioactive isotopes NM gamma camera detects and displays isotope distribution in the patient Therapeutic NM is the administration of radioactive isotopes to treat disease.
– Iodine 131 to treat hyperthyroidism or thyroid cancer
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NM
Advantages
– Images organ and cellular function – Provides complimentary information to compare with CT or other anatomic imaging studies – Therapeutic options

Disadvantages
– Patients and their bodily fluids become radioactive – Some exams require days to complete – Patient must be able to hold still for lengthy image acquisition
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Bone scan Gamma camera

Lung scan

Inject patient (different compound per exam) Renal scan

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Common nuclear medicine exams

Hepatobiliary(DISIDA) scan

NM Single Photon Emission Computed Tomography (SPECT)
Gamma camera rotates around patient and collects data from multiple points (much like a CT scanner) Data reconstructed into multiple different planes

Myocardial SPECT scan
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NM Positron Emission Tomography (PET)
Radioactive glucose injected into patient Most commonly used in imaging cancer patients Cardiac and neurological indications

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PET scanner
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PET scan in patient with lung cancer

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PET/CT fusion

Radiology Charges
Total charge is a combined professional and technical component Professional fee
– Charge for image interpretation

Technical fee
– All other costs including hospital/clinic fee, technologist salary, utilities and supplies

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Representative Charges
Exam CXR UGI NM Bone NM PET MRI head CT head CT abd/pel
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Pro fee $29 $90 $113 $201 $193 $111 $316

Tech fee $109 $253 $462 $2958 $1382 $583 $1654

Total $138 $343 $575 $3159 $1575 $694 $1970

Image Interpretation
MUST know normal radiographic anatomy including different projections MUST have an approach to film interpretation MUST know radiographic appearance of common and life threatening diseases MUST know appropriate utilization and limitations of each imaging modality MUST understand radiographic terminology MUST know ones own limitations
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Different Radiographic Densities
(Different degrees of photon absorption)
Soft tissue Fat Air Bone Contrast Material Foreign material- metal

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Air

Fat Soft tissue (spleen) Bone

CT Densities
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Soft tissue (liver) Air

Fat Bone

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Radiographic density of abnormality helps determine the differential diagnosis

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