Lower Left Lobe Pneumonia

Consolidation of the left lower lobe & Loss of left hemi-diaphragm silhouette

Radiological Diagnosis = Left Lower Lobe pneumonia

The silhouette sign
The silhouette sign is an important radiological principle.  The loss of a silhouette on chest x-ray suggests pathology in the adjacent lung.

Right middle lobe	Right heart border
Right upper lobe	Right Mediastinum
Right lower lobe	Right hemidiaphragm
Left upper lobe	Aortic knuckle
Lingula	Left heart border
Left lower lobe	Left hemidiaphragm

 

 

 

 

Clinical diagnosis:  Pyelonephritis

Radiology report (by clinician)

Several radio-opacities in RUQ in keeping with gall stones. No renal tract calcification.  

There was still a high clinical suspicion of a renal calculus, so the patient proceeded to a CTKUB.
Radiological Diagnosis:  Left ureteric calculus

Advise: CT KUB

Radiological report:

Moderate left hydronephrosis
Left hydroureter to the level of an obstructing 5mm calculus in the proximal ureter. Perinephric fat stranding.

Right kidney normal in appearance.

50-70% of renal tract calculi are visible on a plain abdominal x-ray.

CT KUB is the first line imaging investigation for renal colic.  It is a CT study without contrast.

Most likely clinical diagnosis:small bowel obstruction

AXR:

Radiological report:
Multiple loops of dilated small bowel within the central abdomen
No gas distally in the large bowel

Radiological diagnosis: small bowel obstruction

Bowel Obstruction: Distinguishing Large and Small Bowel Obstruction

Feature	Small Bowel Obstruction	Large Bowel Obstruction
Bowel Diameter:	>3.5cm	>5cm
Position of Loops:	Central	Periphery
Number of Loops:	Many	Few
Fluid Levels (on erect film):	Many, short	Few, Long
Bowel Markings:	Valvaulae conniventes (all the way across)	Haustra (partially across)
Cut off point:	Less likely	Yes
Large Bowel Gas:	No	Yes

Clinical diagnosis: pneumothorax

Radiology report:
Large Right Pneumothorax
No mediastinal shift
Left lung normal

Radiological diagnosis: left sided pneumothorax

Radiological features of pneumothorax

The lung edge is clearly seen
Absence of peripheral lung markings
± mediastinal shift

Look for an underlying cause eg, cystic fibrosis

Tension pneumothorax is a clinical emergency.
Immediate decompression with a large bore cannula in the 2nd intercostal

space in the mid-calvicular line is indicated.

Clinical diagnosis: congestive cardiac failure

Radiology Report:

Alveolar oedema
Kerley B lines (interlobular septal lines)
Cardiomegaly
Distended upper lobe vessels
Bilateral pleural effusions

Radiological diagnosis: Congestive cardiac failure

Be cautious commenting on the heart size on an AP CXR projection.  The heart size is

magnified compared to the standard PA projection.

Clinical diagnosis: sub-dural haematoma

Acute right-sided subdural haematoma.

There is effacement of the right lateral ventricle with midline shift.
Incidental established infarct in the left MCA territory.
Urgent neurosurgical opinion advised.

Radiological diagnosis: subdural haematoma

    Extradural    Subdural
Vessel source    Middle meningeal artery     Dural veins
Shape    Elliptical     Crescenteric
Sutures    Does not cross    Crosses
Midline    May cross    Does not cross
Underlying fracture    Typical     Atypical

Extra-dural and sub-dural haematomas are both extra-axial collections.  Both require neurosurgical opinion.

Clinical diagnosis: Irritable bowel syndrome

Radiology Report:
Radiological Diagnosis: Inflammatory bowel disease: Crohn’s Disease.

Features of Crohn’s Disease on Small Bowel Series

Deep ulcers
Bowel loop separation
Strictures (string sign of Kantor)
Fistula formation
Skip lesions (normal segments between areas of diseased bowel)


Compare and contrast Crohn’s disease and UC

	CROHN’S DISEASE	ULCERATIVE COLITIS
FEATURES	Small and large bowel involvement 40% small bowel only 30% large bowel only 30% both	Confined mainly to large bowel
	Most commonly affects terminal ileum	Most commonly affects the rectum and sigmoid
	Deep ulceration: ‘rose thorn’ appearance	Ulcers less common
	Thickened bowel wall: ‘Cobblestone appearance of mucosa’	Bowel wall is thin
	Stricture formation: ‘String sign of Kantor’	Loss of haustral pattern: ‘Lead pipe’ appearance
	Skip lesions	Continuous lesions
SYMPTOMS	Abdominal pain ± mass	Pain less common
	Altered bowel habit: blood in stools is less common	Bloody diarrhea
	Anorexia common	Weight loss if disease is severe
	Commonly associated with perianal disease	Rarely associated with perianal diseae

     

Clinical diagnosis: Sarcoidosis

Radiology report:
bilateral hilar enlargement (due to lymphadenopathy), Lung clear
Radiological diagnosis: Sarcoidosis

Causes of hilar enlargement

Sarcoidosis *
Lymphoma
Pulmonary hypertension
TB *

Causes of Erythema Nodosum

TB *
IBD
Throat infection (Strep)
Sarcoidosis *
Drugs

* on both lists

Clinical diagnosis: Gastric ulcer

Radiology Report: Free air under the diaphragm
                   

Radiological Diagnosis: Perforated duodenal ulcer

Approximately 80% of perforated duodenal ulcers are H. pylori positive.

H. pylori can be detected using:
a) urease breath test
b) CLO test
c) biopsy with Giemsa stain
d) serology

H. pylori is treated with triple therapy to include:
1. proton pump inhibitor eg omeprazole
2. amoxicillin
3. clarithromycin