07 radiology in surgery tutorial hajhamad m msu
TRANSCRIPT
Radiology in surgerydiagnosis and therapy
Dr. Mohammed HajhamadMB.ChB. (Egypt) M.S (Malaysia)
Department of SurgeryInternational Medical School
Management and Science University
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May 2, 2023
Objectives
1. Become familiar with the basic techniques and principles of
radiological investigation
2. Understand the principles of selection of the most
appropriate radiological technique for a given clinical
problem.
3. Identify the key roles of radiology in the diagnosis and
management of surgical disorders.
4. Understand the principles and indications for radiotherapy in
surgical diseases.
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Remember …
No radiological technique replaces clinical skills.
Do not base clinical decision making on imaging findings alone.
“ Treat the patient and not the X-ray”
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How are radiological techniques used in surgery?
To aid in the diagnosis of a surgical disorderAs an interventional technique to treat a surgical disorder or one of its complicationsTo guide a surgical procedure.
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Today’s topics
X-raysUltrasoundComputed tomography (CT)Magnetic resonance imaging (MRI)Nuclear medicine.Interventional radiologyRadiotherapy
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History
WILHELM CONRAD RONTGENFather of radiologyInvented X-ray in 1895
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History
SIR GODFREY HOUNSFIELDFather of CTInvented CT in 1975
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Radiographs, the basics
The five radiographic densities are in order of increasing brightness:
I. Air2. Fat3. Fluid4. Bone5. Metal.
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Radiographs, the basics
Too darkOver exposure
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Radiographs, the basics
Too brightUnder exposure
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Radiographs, the basics
Sharpness Experiment
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CT scan and MRILamp and the desk are spinning rapidly around your finger.
(experiment)
This situation is analogous to a
In CT scan (Computed Tomography), the x-ray tube (lamp) and the
detector (wall) spin rapidly around the patient.
Information is transferred to a computer and multiple images are
reconstructed.
CT images give the impression of looking at cross-sectional slices of
the patient.
MRI (Magnetic Resonance Imaging) generates cross-sectional images
using a large magnetic field.
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CT and MRI
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Ultrasonography, the basics
Piez0-electric effectPiezo (in Greek) means: squeeze.
Piezoelectric Effect is the ability of certain materials to generate an electric charge in response to applied mechanical stress.
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Ultrasonography, the basics
An ultrasound wave is generated when an electric field is applied to an array of piezoelectric crystals located on the transducer surface. Electrical stimulation causes mechanical distortion of the crystals resulting in vibration and production of sound waves.
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Ultrasonography, the basics
Ultrasound: sound waves at higher frequencies than can be detected by human being (>20,000 Hz)In medicine, we use very high frequency between 2-20 MHz.
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Ultrasonography, the basics
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Ultrasonography, the basics
Acoustic impedance (Z) is a physical property of tissue. It describes how much resistance an ultrasound beam encounters as it passes through a tissue. Acoustic impedance depends on: the density of the tissue (d, in kg/m3) the speed of the sound wave (c, in m/s)
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Ultrasonography, the basics
How difficult its for a sound wave to penetrate material?
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Ultrasonography, the basics
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Nuclear imaging
Radio-isotops (radiopharmaceuticals) are given intravenously or orally. Then, external detectors (gamma cameras) capture and form images from the radiation emitted by the radiopharmaceuticals. There are several techniques of diagnostic nuclear medicine.
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Examples Whole body bone scan – used to identify metastatic cancer involving the bone.Thyroid uptake scan – used to visualize the thyroid gland when disease of the thyroid is suspected.Renal scan – used to indicate the perfusion, function and structure of the kidneys. It is also used to indicate the presence of obstruction or renovascular hypertension.Parathyroid scan – done primarily to detect tumors in the parathyroid gland.Liver/spleen scan – allows for visualization of the liver and spleen. It is indicated for patients with cancer to rule out metastatic tumor in the liver.
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Examples technetium-99m rubidium-82 thallium-201 fluoro-deoxy glucose (FDG)
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Examples
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Examples
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Examples
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Examples
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Examples
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Theraputic radiologyRadiotherapy A clinical modality dealing with the
use of ionizing radiation in the treatment of patients
Cancer treatment
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How Radiotherapy Works ? DNA
Translocations Deletions
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Types of Radiotherapy
•External Beam Radiotherapy: radiation source is outside the patient
•Brachytherapy: radiation source is inside the patient: Intra-cavitary (cervix cancer) Intra-lumenal (esophagus, bronchus) Interstitial (Head Neck, Breast)
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External Beam Radiotherapy
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Interstitial
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Interventional radiology
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What is interventional radiology?
Interventional radiology is a subspecialty which provides minimally invasive diagnosis and/or treatment using imaging (ultrasound, CT, or fluoroscopy) to target the intervention and show the results of the intervention.
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1. Percutaneous biopsy
US, CT or fluoroscopyRandom sampling or sampling of a massLung, mediastinum, pleura, chest wall, nodesLiver, adrenal gland, pancreas kidneys, lymph nodes
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Liver biopsy
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Lung biopsy
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2. Percutaneous abscess drainage
US, CT or fluoroscopyAspiration or drainage tube placementUsually for infectionPleura, lungHepatic (intra/sub), pericolic gutters, perisplenic, peri/intrapancreatic, pouch of Douglas, psoas, abdominal wall
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3. Arteriography
Injection of contrast media directly into arteries and vis via fluoroscopyUsually immediately precedes and intervention is angioplasty, stenting, embolization, thrombolysisAorta, pelvis, lower and upper extremities, kidneys, gut, lungs
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Aortic angiography
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Pelvic embolization post trauma
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13. Foreign body retrieval
Most frequently guidewires or cathetersUsually in the right heart or pulmonary arteryRetrieval under fluoroscopic guidance using snares needed given infection, arrhythmia risk
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Cholangiogram (L), internal external drainage from the L (R)
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Jom ... practice
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RADIOLOGY DIAGRAM
X-ray image
Pathologyimage
Zenker's Diverticulum
Esophageal Cancer
Esophageal Cancer
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Benign Esophageal Stricture
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Achalasia
NORMALESOPHAGUS
DIAPHRAGM
HIATAL HERNIA
DIAPHRAGM
*Note distended distal esophagus with herniation of gastric fundus into chest through esophageal hiatus.
This allows for reflux of gastric contents into esophagus.
Diffuse Esophageal Spasm
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Gastric Ulcer
Barium collects in ulcer crater
Endoscopic view of ulcer
Malignant Ulcer Benign Ulcer
Gastric Carcinoma
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Duodenal Ulcer
Supine … Looking for:Gas in the
rectum/sigmoidGas in ascending or
descending colonDistended loops
Erect .. looking for:free air “under
diaphrams”air-fluid levels
Normal Gas Pattern
○ Stomach Always (except
supine)○ Small Bowel
Two or three loops of non-distended bowel
Normal diameter = 2.5 cm = 1 US quarter
○ Large BowelIn rectum or sigmoid –
almost always
stomach
colon
· Large Bowel¨ Peripheral¨ Haustral markings don't extendfrom wall to wall· Small Bowel¨ Central¨ Valvulae extend across lumen¨ Maximum diameter of 2"
HEPATIC FLEXURE
SPLENIC FLEXURE
TRANSVERSE COLON
CECUM
ASCENDING
COLON
DESENDIN
G COLO
NTERMINAL ILEUM
Normal Colon
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An erect CXR (not AXR) is the best projection to diagnose a pneumoperitoneum (gas in the peritoneal cavity).
Other Signs of Free Air Rigler's sign
air is present on the inside (lumenal side) and the outside (peritoneal side)
ERECT
Ng tube
Small Bowel Obstruction
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Small Bowel Obstruction
Small Bowel Obstruction
DilatedBowel
Non DilatedBowel
OBSTRUCTION*
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Hernia
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ColonObstruction
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Colon Cancer
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Sigmoid Volvulus
“coffee bean sign”
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“beak sign”
Barium fills to point of obstruction and
twist of sigmoid colon
Colon Volvulus
Intussusception Meniscus sign
Chrohn’s Disease
normal
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Chrohn’s Disease
String Signcobblestone mucosa
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Ulcerative Colitis
Lead Pipe Colon ahaustral appearance
Diverticulosis
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Diverticulitis
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Appendicolith
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Ileostomy
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Gall Stones
Porcelain Gallbladder
Nephrocalcinosis
•Hyperparathyroidism •Medullary sponge kidney
ERCP - Normal
ERCP
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Bile Duct Stricture
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MRCP
Small Bowel ObstructionPROXIMAL DILATED
BOWEL
DISTALNORMALBOWEL
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Peritoneal Free air
Retroperitoneal Air
Pneumoretroperitoneum
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Polyp of Transverse Colon
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Gastric Tumor
Tumor of Rectum
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Tumor of Rectum
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Pneumatosis Intestinalis
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Pneumatosis Intestinalis
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Pneumobilia
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GS ilues
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Amebic Liver abscess
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Gas-producing Organisms
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Pyogenic Abscess
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Liver Metastases
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Hepatocellular Carcinoma
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Hernia
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Inguinal Hernia
Appendicitis
NORMAL
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DrainageAbscess
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AAA
Pancreatitis
Pancreatitis
Pancreatitis
Carotid Body Tumor
Carotid Body Tumor
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T1
T2
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Gallbladder Stones + Wall Thickening
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Gallbladder Stones + Wall Thickening
Gallbladder Stones + Wall Thickening
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focal CBD dilatation in the distal part
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Anechoic Liver Lesions
CBD is dilated measuring 1 cm with tiny stone
multiple gallstones with mild thickening
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Malignant Breast Lesion
Pathological Axillary Lymph Node