AMIRUL MUKMIN BIN ZARAHMAN @

MUHAMAD ZULKARNAIN
01MBBS-2020090236
CHEST IMAGING

Imaging Modalities
1. Plain radiograph (CXR) *cheap,
fast & low radiation
2. CT
3. MRI
4. Ultrasound

CXR Interpretation
▪ Check clinical hx
▪ Check info on CXR
(Pt’s data/ previous film)
▪ Check the technique
(Projection, inspiration,
rotation & exposure)
▪ Evaluate structures
(trachea, hilum heart,
costophrenic angles,
diaphragms.)
▪ Check lung fields.
▪ Check bones & soft tissues.
▪ Find alien equipment.

Projection
PA view : Clavicles are 5cm below
the lungs’ apex. Most common.
Healthy pt.
AP view : Clavicles are over the
lungs’ apex. In sick pt who is
unable to stand.
Lateral view :

Right Lung Left Lung

Lateral decubitus :
Inspiration
Was the film taken under full inspiration?
Good inspiratory film :
▪ 6 anterior ribs visible.
▪ 10 posterior ribs visible.
Rotation
Equal distance between medial end of
clavicle to midline (spinous process).
Exposure
Overexposed
Underexposed
1. Trachea
(N: centrally located)
▪ Is it centrally located?
▪ Any deviation to any sides?
▪ Any foreign bodies?
▪ Any main bronchus cutoff?
2. Hilum
(N: both hilum are identical in size,
shape & density)
▪ L hilum is higher than R hilum.
▪ Compare both sides on size, shape
& density.
3. Heart & mediastinum
(N : heart is normal in size & no
mediastinal shift)
▪ CT/ratio on: PA < 50%, AP < 60%
▪ Size of the heart chambers
▪ Silhouette margin should be sharp
▪ Pulmonary vessels size
▪ Any stents, clips or wire?
▪ Outline the aorta, IVC & SVC
▪ Any mediastinal shift/widening?
4. Costophrenic angles
(N : Both costophrenic angles are
sharp)
▪ Blunting of the angles are
suggestive of pleural effusion.
5. Diaphragm
(N : No air under diaphragm)
▪ R hemidiaphragm is higher than L
(due to liver on the R)
▪ Are the hemidiaphragms
flattened/elevated?
▪ Is there any air under the
diaphragm? (Suggestive of viscous
perforation)
 6. Lung fields Air bronchogram sign
(N : both lung fields are clear) - An air-filled bronchi on the
▪ Symmetrical on both sides? background of alveolar
▪ Density on both sides? consolidation.
- Radiopacity (whiteness) :
increase density
- Radiolucent (blackness) :
decrease density
▪ Lung markings
▪ Any focal lesions? Nodules<3cm,
Mass>3cm.

7. Bones & soft tissues

(N : no bones or soft tissues lesion)
▪ Any fractures/lesions/erosions on
the visualize bones (humerus,
If there is any lesion, describe it according
clavicle, ribs)?
to :
▪ Any tissue swellings? - Definition (well defined or ill-
▪ Any vertebral column defined)
abnormalities?
▪ Any breast tissue variations seen? - Type (opacity, cavity, nodule and
mass)

8. Alien equipment - Size and shape (rounded, oval or

▪ Any surgical clips, pacemaker, lobulated)
chest leads, chest tube attached to
- Multiplicity (single or multiple)
the pt?
- Location
Common Radiological Findings
Silhouette sign
- Loss of normal roentgen of
silhouette or outline sign.

RUL LUL

RML Lingula

RLL LLL
Chest Imaging Pathology - Primary tuberculosis:

1. PNEUMONIA
▪ Consolidation (radiopacity)
▪ Indistinct margin.
▪ Diffuse/localized.
▪ Presence of air bronchogram sign
on CXR.

- ill-defined consolidation in the

right upper zone with enlargement
of the draining lymph nodes

- Post primary tuberculosis

NORMAL ▪ Usually distributed in
apical/posterior segments of
upper lobe
▪ Superior segments of lower
lobes
▪ Air space consolidation
▪ Unilateral/ bilateral
▪ Healing with fibrosis

LLL PNEUMONIA

2. PULMONARY TUBERCULOSIS
Primary pulmonary TB
▪ May involve any lobes
(predominantly lower lobe)
▪ Air space consolidation
▪ Usually unilateral
Complications of Post-Primary TB 4. BRONCHIAL ASTHMA
➢ Endobronchial spread / infection ▪ Majority of pts had normal CXR.
- localized consolidation and / or ▪ CXR changes maybe present in
cavitation severe/chronic asthmatic pt
➢ Pleural effusion - Bronchial wall thickening
➢ Miliary TB - Hyperinflation
➢ Tuberculoma – alternating - Flattening of the
activation & healing of localised diaphragm
parenchymal disease
➢ Mycetoma/ aspergilloma - in
chronic tuberculous cavities,
colonized by fungus
Usually CXR done for detection of possible
complications such as:
▪ Pneumothorax
air crescent sign ▪ Pneumoperitoneum
▪ Pneumonia
▪ Atelectasis

aspergilloma

3. MILIARY TUBERCULOSIS
Innumerable 1-3 mm, non-calcified
nodules scattered through both
lung fields with basal
predominance.
 5. EMPHYSEMA
Radiographic features
Hyperinflation
Flattened diaphragms
Elongated narrow heart appearance
Diffuse lucency and bullae
Increased retrosternal space
8. PNEUMOTHORAX
6. BRONCHOPNEUMONIA
▪ Primarily affecting bronchi &
adjacent alveoli
▪ Volume loss (exudate filling the
bronchi)
▪ Bronchial spread = multifocal
patchy opacity (consolidation)
7. PLEURAL EFFUSION
- Homogenous radiopacity
- Smooth sharp meniscus
- Blunting of costophrenic
angle
- Gas shadow between
peripheral margin of the lung &
chest wall, diaphragm, or
mediastinum.
- Visible pleura line bordered by
air in the pleural space and
aerated lung.
- Air-fluid level
- Abnormal radiolucency of
affected lung field (featureless
lungs).
Emergency : mediastinal shift suggesting
TENSION PNEUMOTHORAX
▪ Deep sulcus sign = on frontal view
larger lateral costo-diaphragmatic
recess than on opposite side
▪ Total / subtotal lung collapse

PARTIAL LUNG COLLAPSE

9. COLLAPSE (ATELECTASIS)
Partial or complete loss of lung volume.

SIGNS :

DIRECT INDIRECT

•Displaced interlobar •Tracheal deviation to

fissure affected side
•Loss of aeration •Hemidiaphragm
(Increase density) elevation
•Vascular/bronchial sign •Mediastinal shift
(vesse/ bronchi •Hilar displacement
crowding) •Compensatory
hyperinflated
contralateral lung
COMPLETE LUNG COLLAPSE

R MIDDLE LOBE COLLAPSE

 Alveolar Pulmonary Edema
▪ Bat’s wing appearance

L LOWER LOBE COLLAPSE

10. PULMONARY EMBOLISM
▪ Westermark’s sign- Oligemia of
9. PULMONARY EDEMA
▪ Kerley “B” Lines the lung beyond the occluded
vessel
▪ Peribronchial cuffing
▪ Enlargement of the central
▪ Ill-defined vessels pulmonary artery by impaction of
▪ Larger upper lobe vessels embolus (Fleischner sign)

▪ Fluid in fissures ▪ Hampton’s hump-pulmonary

infarction
▪ Small pleural effusion
▪ Atelectasis, consolidation and
elevation of the ispilateral
hemidiaphragm
▪ Pleural effusion

Interstitial Pulmonary Edema

11. ASCENDING AORTIC ANEURYSM (AAA)

12. DESCENDING AORTIC ANEURYSM

Ruptured aneurysm = HAEMOTHORAX

ABDOMINAL IMAGING AXR Interpretation
▪ Check clinical hx
Imaging Modalities ▪ Check info on AXR film
▪ Check the projection
Plain abdominal film
▪ Look for any :
Barium studies o Dilated bowel loops
o Free intraperitoneal gas
Ultrasound o Ascites & soft tissues
masses
Computed Tomography (CT) o Calcifications
▪ Assess liver & spleen size
▪ Check bones for :
PLAIN ABDOMINAL PLANES
Erect Chest Supine Erect Left Lateral o Joint & disc space
Abdomen Abdomen Decubitus o General bone density
Abdomen
Best for Best for For air- For free air and
o Lysis, fracture & sclerosis
free air abdominal fluid air-fluid levels
under the details: levels SUPINE AXR
diaphragm organs,
the Small Large bowel
distribution of bowel
abdominal
gas, the
Valvulae + -
caliber and conniventes Stack of
mucosal (complete coins
pattern of
gas-filled
band across appearance
bowel, the width
displacement of the
of bowel
loops by soft
bowel)
tissue masses Haustration - +
or fluid and (incomplete
calcifications
bands cross
⅓ of the
bowel
width)
Diameter > 3cm > 6cm
Location Central Peripheral
No. of loops Numerous Few

Supine Erect
 Shape Kidney Inverted ‘U’
shape shape
Haustration + -
Vertical - +
S. bowel dense white ‘coffee bean’
line appearance
(inner wall
of bowels
opposing
each other)
L. bowel
Erect abdomen
SUPINE ABDOMEN:

ERECT AXR
Small Large bowel
bowel
Air-fluid Multiple Multiple with
level with ‘step ‘step ladder
ladder appearance’ &
appearance’ long segment
& short
segment
String of + -
beads
SUPINE AXR
Caecal Sigmoid ERECT AXR
volvulus volvulus Caecal Sigmoid
Extension Air-filled Air-filled dilated volvulus volvulus
dilated bowel loops 1 air-fluid 2 air-fluid level
bowel extending from level
loops pelvis inferiorly
extending to R
from RIF hemidiaphragm
inferiorly superiorly.
to LUQ
superiorly.
Apex Midline / R/L
LUQ hemidiaphragm
Free intraperitoneal gas
(N : No free intraperitoneal gas
/pneumoperitoneum)

Signs of pneumoperitoneum on supine Triangular sign : gas collecting

AXR : between adjacent bowel loops.

Ascites & soft tissues masses

(N: No ascites/soft tissue mass)

▪ Gray abdomen
▪ Central placement of bowel loops
▪ Floating centralized small bowel
loops
▪ Separation of loops
▪ Loss of definition of the liver
Rigler’s sign : bowel wall outlined by and/or spleen edge
intraluminal (normal) and peritoneal gas ▪ Bulging flanks
(abnormal)

Football sign : a large lucency outlining the

entire abdominal cavity.
 ▪ Soft tissue mass arising out of
pelvis (arrows) displacing bowel to
the sides of the abdomen.
(Cystadeno-carcinoma of the
ovary)
Bones
(N: No bony lesion)
Check for :
▪ Joint & disc space
▪ General bone density
▪ Lysis, fracture, sclerosis
BARIUM STUDIES

Upper GI Lower GI

• Barium • Barium enema

swallow
• Barium meal
• Small bowel
enema

Calcifications
(N: No abnormal calcifications)

Liver & spleen size

(N: No hepatosplenomegaly)

PEPTIC ULCER

DIVERTICULOSIS COLON CA
 ACUTE CHOLECYSTITIS
ULCERATIVE COLITIS

Focused Abdominal Sonography for

Trauma (FAST)
▪ Detection of Free Fluid secondary
Lead pipe colon appearance to abdominal organs injury.
▪ Shortening of colon secondary to
fibrosis
▪ Loss of haustration

CROHN’S DISEASE

COMPUTED TOMOGRAPHY (CT SCAN)

▪ Discontinuous lesion of the bowel
Indications
▪ Skip lesion sign
ULTRASOUND
Evaluation of solid organs
(Liver,pancreas, spleen, KUB)
Characterization solid,cystic / complex
lesions
Evaluating non-palpable, intraabdominal
& retroperitoneal mass
Assessment of small amount of fluid
collection in peritoneal space
▪ Evaluating the abdominal walls,
intraperitoneal, retroperitoneal
spaces, all organs & potential
spaces.
▪ Evaluating entire abdomen for
masses & extension to adjacent
structures
▪ Differentiating between solid &
cystic masses, exudate vs
transudate & calcifications vs
masses
▪ Abdominal trauma
LIVER LACERATION

Commonly occur along natural planes of

hepatic vessels & fissures.

Liver laceration along fissure of

ligamentum teres.

Multifocal right hepatic lobe lacerations

with a focus of active hemorrhage and
perihepatic hematoma.