imaging and laboratory test in medicine

24.11.2016

1

Laboratory tests and imaging in medicine

Tomas Koller

Symptoms Clinical sign Clinical diagnosis + =

Diagnosis

Etiological diagnosis

T.K.

Differential diagnosis 1. Differential diagnosis 3. Differential diagnosis 2.

Age Gender Medical and Surgical history

Laboratory tests Medical imaging

Osnova/outline

1. Complete blood count

2. Blood coagulation

3. Serum biochemistry

4. Urine analysis

5. Imaging 1. Chest X ray

2. Abdominal X ray

3. Abdominal ultrasound

4. CT and MRI

5. Endoscopy

1. Complete blood count

• Leucocytes

• Erythrocytes

• Hemoglobin

• Haematocrit

• Mean cellular volume

• Mean hemoglobin conc.

• Platelets

• Reticulocytes

Complete blood cell count Differential white blood cell count

• Neutrofils

• Lymphocytes

• Monocytes

• Eosinophils

• Basophils

• Absolute count

• Relative count

– % of total leucocytes

24.11.2016

2

• Leucocytes • Erythrocytes • Hemoglobin • Haematocrit • Mean cellular volume • Mean hemoglobin conc. • Platelets

• 4 – 10.109/l • < Leucopenia

– Decreased production • Bone marrow

– Sequestration • spleen

– Increased consumption • sepsis

• > Leucocytosis – Demarginalisation

• infection

– Increased production • Bone marrow proliferation

Complete blood cell count

• Leucocytes

• Erythrocytes

• Hemoglobin

• Haematocrit



• Platelets

• 4 – 6 . 1012/l

• <anemia

– Descreased production

– Destruction

– Sequestration

• >polyglobulia, polycytemia

– Proliferation

– Hypoxia


• Leucocytes

• Erythrocytes

• Hemoglobin

• Haematocrit



• Platelets

• 120-175 g/l

• Anemia

– Mild <120

– Moderate <100

– Severe <80

• Polycytemia


• Leucocytes

• Erythrocytes

• Hemoglobin

• Haematocrit



• Platelets

• 40-50 %

• >50% polycytemia

• < 40 % anemia


• Leucocytes

• Erythrocytes

• Hemoglobin

• Haematocrit



• Platelets

• 80-100 fl

• Microcytosis < 80 fl – Anemia

– Hemoglobinopathies

• Normocytosis 80-100 fl

• Macrocytosis > 100 fl – Anemia

– Ethanol abuse

– Hyperlipidemia

– Bone marrow dysplasia


• Leucocytes • Erythrocytes • Hemoglobin • Haematocrit • Mean cellular volume • Mean hemoglobin conc. • Platelets

• 150 – 400 . 109/l • Trombocytosis

– Inflammation – Iron deficiency – Proliferation – Splenectomy

• Trombocytopenia – Consumption

• bleeding

– Sequestration • spleen

– Decreased production • Bone marrow disease • Chemotherapy • Radiation


24.11.2016

3

• Relative count – 0.5-1.5% RBC

• Absolute count – 27-75 . 109/l

• Reticulocytosis – >1.5%

– increased RBC production

– hemolysis

– correction of Fe or vB12 deficit

• Reticulocytopenia – <0.5%

– reduced RBC production

• Leucocytes

• Erythrocytes

• Hemoglobin

• Haematocrit



• Platelets

• Reticulocytes

Complete blood cell count Differential white blood cell count

• Neutrofils • Lymphocytes • Monocytes • Eosinophils • Basophils

• 46-73% • Number of segments (

– Nonsegmented • Younger cells • Shift to left

– Segmented • Older cells • Shift to right

• Neutrophilia > 73% – Bacterial infection – Stress

• Neutropenia – <1 . 109/l neutropenia – <0.5 109/l agranulocystosis

Differential white blood cell count

• Neutrofils

• Lymphocytes

• Monocytes

• Eosinophils

• Basophils

• 18-44%

• Lymphocytopenia – Bacterial infection

– Proliferation of other clones of cells

– Severe disease

• Lymphocytosis – Viral infection

– Autoimmune dis.

– Clone proliferation • lymphoma


• Neutrofils

• Lymphocytes

• Monocytes

• Eosinophils

• Basophils

• 2-12%

• Monocytosis

– Viral infection


• Neutrofils

• Lymphocytes

• Monocytes

• Eosinophils

• Basophils

• 0-5%

• Eosinophilia

– Allergic reactions • Atopic disease

• Asthma

• Drug induced allergies

– Parasitic infection


• Neutrofils

• Lymphocytes

• Monocytes

• Eosinophils

• Basophils

• 0-1%

24.11.2016

4

2. Blood coagulation

Blood coagulation

Test Units Normal values

• INR >1.2

– Drugs • Warfarin

– Liver disease

– Consumption • Bleeding

• APTT-R>1.2

– Drugs • Heparin

• LMW heparin

• New anticoagulants

– Liver disease

– Consumption

• Hyper-fibrinogenemia

– Inflammation

– Cancer

– Operation

• Low fibrinogen

– Consumption • Bleeding

• DIC

– Low synthesis • Liver dis.

In practice blood count and coagulation

24.11.2016

5

3. Serum biochemistry

Serum biochemistry

• Glucose • Creatinine • Urea • Total protein • Albumin • Bilirubin • AST, ALT • GGT, ALP • Amylase,lipase • Sodium (Na) • Potassium (K) • Chlorine (Cl) • Calcium (Ca) • Phospshorus (P)

Serum biochemistry


• 4.0-5.5 mmol/l

• Hypoglycaemia < 4.0 mmol/l – Fasting – Drug induced – Insulinoma

• Hyperglycaemia >5.6 mmol/l

• Diabetes mellitus – >7.0 mmol/l – 11.1 mmol/l 2 h post 75 g glucose challenge

• Prediabetes

– Impaired fasting glucose 5.6-7.0 mmol/l – Impaired glucose tolerance 7.8-11.1 mmol/l

2 hours post 75 g glucose challenge

Serum biochemistry


• M 62 – 106, F 44 – 80 umol/l • M 2.8 – 8.0, F 2.0 – 6.7 mmol/l • Low

• Decreased muscle mass

• High • Decreased renal clearance • Dehydration • Renal insufficiency • Renal failure

• Calculated parameters

– Glomerular filtration rate – Normal >1.5 ml/s

Serum biochemistry


• TP 57-82 g/l, ALB 32-48 g/l • Low

– Low synthesis • Cirrhosis • Malnutrition • Inflammation

– Increased loss • Nephrotic syndrome • Preeclapmsia • Protein loosing enteropathy

• High

– Clonal proliferation – myeloma – Dehydration

Serum biochemistry


• 34-17.1 umol/l • Total bilirubin

– Conjugated bilirubin – Unconjugated bilirubin

• Hyperbilirubinemia – Unconjugated

• Benign • Haemolysis

– Conjugated • Biliary obstruction • Liver disease with impaired function

24.11.2016

6

Serum biochemistry


• Aspartate amino transferase – M 0.17 – 0.85, F 0.17 – 0.60 ukat/l

• Alanine amino transferase – M 0.20 – 0.80, F 0.20 – 0.60 ukat/l

• Cytolytic enzymes

• Hepatocyte injury

– ALT>AST

• Alcohol – AST>ALT

Serum biochemistry


• Gamma-glutamyl transpeptidase • Alcaline phosphatase • Cholestatic enzymes • Both high

– Impairement • in bile production or • in bile transport from hepatocytes to intestine

• GGT (M 0.18 – 1.02, F 0.15 – 0.65 ukat/l)

– Inducible enzyme by drugs, alcohol – In steatosis – In cholestasis with ALP

• ALP (M 0.67 – 2.15, F 0.58 – 1.74 ukat/l) – Cholestasis with GGT – Placental ALP – Bone ALP fraction

Serum biochemistry


• Amylase and lipase – AMS 0-1.67 ukat /l – Lipase 0-1 ukat/l

• Increased in pancreatic damage – Pancreatitis

• AMS > more than 3 times ULN – > 5 ukat/l

• Lipase

– more specific for pancreas

Serum biochemistry


• Sodium • 132-146 mmol/l • Principle extracellular cation

• Hyponatremia

• Hypernatremia

Serum biochemistry


• Potassium • 3.5-5.5 mmol/l • Hypokalemia

– Fluid loss • Vomiting • Diarrhea

– Decreased intake • fasting

• Hyperkalemia – Renal failure

Serum biochemistry


• Calcium total – 2.0-2.75 mmol/l

• Calcium ionized – 1.1-1.35 mmol/l

• Hypocalcemia

• Hypercalcemia

24.11.2016

7

Protein eletrophoresis

4. Urinalysis

, blood

Urine color

Urinalysis

• Urine biochemistry

Density pH Proteins Bilirubin Hemoglobin Glucose Ketones Urobilinogen Nitrites Leucocytes

Urinalysis

• Urine sediment

Erythrocytes Leucocytes Hyaline casts Other casts

Urinalysis

• Urine proteins

< 0.15 g/24 hours

> 0.5 g/ 24 severely elevated

> 3.5 g / 24 hours – nephrotic proteinuria

• Albuminuria

– Microalbuminuria – mild impairement

– 30-300 mg/liter or mg/24 hours

24.11.2016

8

Urinary casts

Urinalysis Crystals

5. Imaging

5. Imaging

1. Chest x ray

Normal Chest X ray

24.11.2016

9

Chest x ray Ribs

Fractured ribs

Chest X ray Angles

Chest X ray The heart

Pericardial effusion Consolidation

24.11.2016

10

Consolidation

• Density in left lower lung field

• Loss of left heart silhouette

• Diaphragmatic silhouette intact

• No shift of mediastinum

• Blunting of costophrenic angle

Consolidation

• Density in right upper lung field

• Lobar density

• Loss of ascending aorta silhouette

• No shift of mediastinum

• Transverse fissure not significantly shifted

• Air bronchogram

PLEURAL EFFUSION

• Homogenous density

• Meniscus maximum in axilla

• Loss of cardiophrenic angle

• Loss of diaphragmatic and right cardiac silhouette

MASSIVE PLEURAL EFFUSION

• Massive

• Shift of mediastinum

ATELECTASIS RIGHT LUNG

• Homogenous density right hemithorax

• Mediastinal shift to right

• Right hemithorax smaller

• Right heart and diaphragmatic silhouette are not identifiable

LEFT LOWER LOBE ATELECTASIS

• Inhomogeneous cardiac density

• Left hilum pulled down

• Non-visualization of left diaphragm

• Triangular retrocardiac atelectatic LLL

24.11.2016

11

PLEURAL FIROSIS

• Small right hemithorax

• Diffuse haziness

• Tracheal shift to right

• Blunted costophrenic angle

• Lines not corresponding to fissures

TUBERCULOSIS

• LUL cavities

• RUL infiltrate

• Bilateral upper lobe disease

TUERCULOSIS

• LUL cavity

• Cavity behind clavicle - note increased density of clavicle in the region over lying cavity

• Pleural effusion on right

MILIARY TUBERCULOSIS

• Interstitial nodules

– Uniform size

– Sharper edges

PNEUMOTHORAX

• No vascular markings on right

• No shift of mediastinum to left

• Deep sulcus

• Atelectatic right lung

• Increased haziness on left: Diversion of entire cardiac output

• Small fluid level near costophrenic angle: Hydro pneumothorax

TENSION PNEUMOTHORAX

• No vascular markings on right • Shift of mediastinum to left • Deep sulcus • Atelectatic right lung • Increased haziness on left:

Diversion of entire cardiac output

24.11.2016

12

PANCOAST TUMOUR

• Right apical mass

• Cavitating mass

• Para tracheal nodes

• 2nd rib destruction

• Calcified nodes (silicosis)

LARGE CELL CANCER

Large Cell Cancer

• Mass RUL

LUNG MASS

Mass

• Round or oval

• Sharp margin

• Homogenous

• No respect for anatomy

• Lung Cancer: Large cell

LUNG ABSCESS

Lung Abscess

• Bilateral

• Multiple

• Fluid level

LUNG ABSCESS

Lung Abscess

• Anterior segment of LUL

• Atypical location for aspiration lung abscess

• Thick wall

• Fluid level

PULMOARY EDEMA

• Bilateral

• Diffuse

• Butterfly pattern

• Soft fluffy lesions

• Coalescing

• Air bronchogram

24.11.2016

13

EMPHYSEMA

• Hyperinflation

• Hyperlucency

• Low set flat diaphragm

• Vertical heart

• Pre and infra cardiac lungs

• Barrel shape

• Avascular zones

• Cephalization of upper lung fields is not evident

• Predominant basal involvement (not evident)

• 1. Atelectasis

• 2. Pleural effusion

• 3. Pneumonia

• 4. Post-pneumonectomy

Opacified hemithorax

Multiple Lung Nodules

• 1. Metastasis

• 2. Wegener’s granulomatosis

• 3. Rheumatoid nodules

• 4. AVMs

• 5. Septic emboli

Pulmonary Interstitial Edema

• 1. congestive heart failure

• 2. Lymphangitic spread

• 3. Allergic reaction

Congestive heart failure Hilar Adenopathy

• 1. Sarcoidosis

• 2. TB

• 3. Lymphoma

• 4. Bronchogenic ca

• 5. Metastasis

24.11.2016

14

Dissecting aortic aneurysm

5. Imaging

2. Abdominal x ray

Abdominal X ray

• Plain abdomen

• No preparation

• Standing position

Pneumoperitoneum

Air-fluid levels Small intestinal obstruction

Air in the GI tract

• Meteorism/tympanism

• Some air-fluid levels

24.11.2016

15

Toxic megaloconon

Renal calculi

5. Imaging

3. Abdominal ultrasound

Adominal ultrasound

• Liver and liver veins

• Gallbladder and bile duct

• Pancreas

• Kidneys

• Spleen

• Aorta, vena cava, iliac vessels

• Urinary bladder

The liver

24.11.2016

16

Gallbladder and bile duct

Pancreas

Kidney and spleen Aorta

5. Imaging

4. CT scan and MRI

CT scan

Right side Left side

24.11.2016

17

CT and MRI largely complementary

MRI • Brain (tumors) • Bones • Joints • Muscles • Liver • Small intestine • Vessels • Biliary and pancreatic ducts

– MR cholangio-pancreaticography

• Structural imaging – MRI spectroscopy – MRI elasgography – Diffusion of protons

CT

• Brain (trauma)

• Thyroid

• Lungs and mediastinum

• Abdominal organs

• Acute abdomen

• Colon

• Vessels

• Functional imaging (PET CT) – Small tumors

Magnetic resonance cholangio-pancreaticography (MRCP)

Common bile duct

Main pancreatic duct

5. Imaging

5. Endoscopy

Upper GI endoscopy Gastroscopy

Lesions on the GI mucosa – ulcers, polyps, tumors, inflammation, varices Indications: dysphagia, abdominal pain, hematemesis, melena, anemia, dyspepsia

Lesions of the colon mucosa: polyps, tumors, inflammation Indications: Lower GI bleeding, chronic diarrhea, microcytic anemia, cancer prevention, abdominal pain

Lower GI endoscopy Colonoscopy

Endoscopic retrograde cholangio-pancreaticography

ERCP

Selective cannulation Bile ducts or pancreas

Indications: Therapy only Papilotomy Biliary stone removal Stenting of the biliary or pancreatis stenosis

24.11.2016

18

Thank you !

imaging and laboratory test in medicine

Documents