MEDICAL SKILLS OF RADIOLOGY

MEDICAL SKILLS OF RADIOLOGY

NORMAL THORAX AND NORMAL ABDOMEN

GENERAL OBJECTIVES:

Upon the completion of practicum, students are expected to be able to:

1. Identify radiology anatomy (imaging) on plain photo of normal thorax
2. Identify radiology anatomy (imaging) on plain photo of normal abdomen.

SPECIFIC OBJECTIVES:

Upon the completion of practicum, students are expected to be able to:

1. Identify radiology anatomy (imaging) on plain photo of normal thorax

1.1. position

1.2. symmetricalness  

1.3. inspiration

1.4. condition

2. Identify radiology anatomy (imaging) on plain photo of abdomen.

2.1. position

2.2. organs of internal abdomen cavity (abdomen wall, hepar, renal out line, bone system)

2.3. air distribution in digestion system

1. NORMAL THORAX

Radiology imaging for plain photo of thorax examination is not quite different from thorax anatomy imaging of normal human. Students must have studied carefully the thorax cavity anatomy with the organs of thorax cavity and their vascularisation. Before the students are introduced to various kinds of diseases of heart, lungs and involved organs internal thorax cavity, they must have studied the normal thorax radiology imaging so that later when they encounter abnormalities involving thorax, they can identify them well.

(Picture of Normalthorax radiology imaging, posteroanterior position)

(picture of normal thorax imaging of lateral position)

On the photo of normal thorax, things that should be kept in mind are:

1. position
2. symmetricalness
3. inspiration
4. condition

1. Position

Thorax photo should be in erect position, except on children patients and patients with several general conditions; photo can be made in the position of supine. The projection light direction is from pa position (posteroanterior) that becomes the standard for thorax photo or AP to see the bone condition.

to differentiate the erect and supine positions, this chart below will help:

erect	Supine
Under hemidiafragma sinistra there is air imaging in fundus gaster, called as megenblase	The air in the gaster moves down, so that because there happens superposition with intra abdomen organs, this air is invisible.
Projection PA	Projection PA
Scapula does not cover lung field.	Scapula is on lung field
	Vertebrae imaging looks clear to thoracal 12

2. Symmetricalness

Thorax photo is made in symmetrical, that is, going through the area crossing through median line, drawn through spinosus prosesus dots. It is called symmetrical when the area has the same distance between left-right stemoclavicula ankle.

3. Inspiration

Thorax photo should be done in maximum inspiration condition. If not then there will appear imaging on the photo:

-         Sizes of heart and mediastimun increase

-         Broncovascular color increases

If the inspiration is sufficient, there appears diaphragm as high as rawan costa VI at the front or as high as VTh X in the back.

4. Condition

Condition is a factor that determines X-ray quantity at the time of exposure. In insufficient condition, thorax photo will look white/blurred. In sufficient condition, vertebrate can be seen entirely starting from VCI through Th IV and in hard condition, it can be seen through thoracal vertebrate XII.

After those things have been evaluated, reading photo is then conducted. In order that there is no single thing missing, it can be done from lateral to medical or vice versa from superior to inferior, etc.

Items to be observed:

a.    Bronkhovascular color: normally, the nearer to lateral, the fainter the color. When the color can still be seen on the lateral lung area, it means the bronkhovascular color is increasing.

b.    Lung parenkin: normally, calcification or infiltrate on lung field cannot be seen.

c.    Hylus condition

d.    Sinus costofrenikus: normally, left-right sinus costofrenicus is sharp and not covered by anything.

e.    Diaphragm: normally, left-right diaphragm are smooth, in the form of concave leaning to lung.

f.      Cor: observed for the size and shape. In adults, normally it forms like a shoe and ctr (cardio thoracic ratio) less than 0,5.

Other important factors in reading a photo: identity, i.e., patient’s name, age, date and reading time, marker.

Example of thorax photo reading of normal position:

-         Both lung apexes look steady/calm

-         Bronkhovascular color is seen on both normal lung fields

-         Left-right sinus costophrenicus look sharp

-         Left-right diagraph are smooth

-         Cor: ctr is less than 0.56

Impression: lung and cor are in normal limit

2. NORMAL ABDOMEN

On the plain photo of abdomen, there are several things that should be considered:

1. Air imaging in intestine

Air imaging in lumen of digestion channel on the plain photo of abdomen looks lucent and line imaging is also seen (from lumen on intestinal). Normal imaging of air in abdomen: it is normal when internal large intestinal. Duodenum, small intestine is filled a little with air and can be seen again clearly in the colon. Small intestine usually looks in central and small-sized while large intestine is in periphery and has relatively bigger size.

(PICTURE OF NORMAL PATTERN OF AIR IN LARGE, SMALL INTESTINE AND COLON)

2. Soft tissue and visceral out lines of intra abdominal organs

Outlines on soft tissue shows the radiolucent illustration because there is fat layer scoping the intra abdomen organs. Some organs that sometimes can be seen are: hepar, lien, both kidneys (renal outline), maor muscullus psoas and muscullus quadratus lumborum (psoas line).

Internal jejenum, valvulae conniventes appears: ordered thin lines spreading all over lumen diameter. Internal ileum, it does not cause the appearance of the pattern of mucosa ileum folds. The normal diameter of small intestine is no more than 3 cm.

(PICTURE OF AIR IN THE SMALL (CENTRAL) AND LARGE PERIPHERY INTESTINES) (contast photo)

Imaging of Plain Photo of Abdomen on Children

Imaging of plain abdomen on neonatus shows the existence of air in the stomach (10-15 minutes after delivery), air in small intestine proximal 30-60 minutes after delivery, air in small intestine distal ± 6 hours after delivery and air in colon and rectum ±24 hours after delivery.

Generally, plain photo of abdomen on children is different from adults:

1. Children possess less fat (preperitoneal fat line) than adults, imaging of internal abdomen organs is like renal outline, musculus psoas sign is not as good as adults. We can see the inferior limit from hepar and lien if the intestine air does not cover it (superposition)

On neonatus and children, it has more air than adults, and we can see the air in the small as well as large intestine. We cannot differentiate the imaging of the air in small and large intestines on neonatus and children because it has no mucosal folds. Sometimes the air position in the abdomen cavity can differentiate if it is from small or large intestine. If there is air picture in intestine on edge, there is big probability that it is from large intestine, but if it is in central, the probability is from small intestine.

Imaging: plain abdomen on new born baby

SOURCE : dr. Ana Madjawati FK UMY