Chpt 13 Normal thoracic aorta o XR: (figure 13.

.9) ascending aorta more medial than right heart border aortic knob<35mm (trachea to lateral border of knob) descending thoracic aorta normally parallel with thoracic (almost disappearing) o CT&MRI Normal width Ascending or descending = <3.5cm Aortic knob = <3 Aneurysm = >4 aneurysm Rupture risk = 5-6cm o Aneurysms defined as enlargement >50% of its normal size Cavitating lung lesions o Bronchogenic carcinoma o TB o Lung abscess Apical lung Cancer = Pancoast tumor (figure 13.21) o Soft tissue mas in apex o Most often: squamous cell or adenocarcinoma o May invade ribs or brachial plexus (causing horners syndrome) o R side may produce superior venal caval obstruction Common primary sites of metastatic lung nodules Males Females o Colorectal o Breast o Renal o Colorectal o Head&neck o Renal o Testicular&bladder o Cervical&bladder o Malignant melanaoma o Malignant melanoma o Sarcomas o Sarcomas o Chpt 14 Basics of CT o Dense substances: increased attenuation, white o Less dense substances: low CT numbers, decreased attenuation, blacker Other CT o High resolution CT: useful for diffuse parenchymal lung disease o Spiral CT:seamless o Multislice Multiple nodules in lung most often mets

With contrast = enhanced o Indications: PE Mediastinal mass or adenopathy Aortic aneurysm or dissection Blunt or penetrating trauma Characterize pleural disease Densitometry of pulmonary mass Evaluate coronary arteries CT PA (pulmonary angiography) o Fast spiral CT with rapid bolus of IV contrast o PE, COPD o Replacing V/Q scan as its is sensitive in excess of 90% Hamptons hump (fig 14.9) o Wedge-shaped, peripheral airspace density o Associated with filling defects in pulmonary arteries o Differential: pneumonia, lung contusion, aspiration COPD o XR (fig 14.12) Hyperinflation, flattening of diaphragm Increase retrosternal clear space Hyperlucency Prominent pulmonary arteries o CT (helpful in evaluating extent and planning surgery) Focal low density Pulmonary contusion (fig 14.19) o Peripheral, often at point of impact o Air bronchograms not present o Can present as airspace disease (pneumonia, aspiration) so take good hx

Chpt 15 Normal abdomen screening o Overall gas pattern o Extralumenal air o Calcifications o Soft tissue masses Gas pattern (fig 15.1) o Air in stomach (& air fluid levels) (fig 15.6) Air-fluid level seen with horizontal beam! o Air in 2-3 loops nondistended small bowel (nondistended <2.5cm) May see 2-3 air-fluid levels

o Air in rectum or sigmoid, with varying amounts throughout the rest of colon o Stool has multiple, small bubbles of gas (fig 15.4) Extraluminal air: beneath diaphragm, pleural effusion, pneumonia Calcifications o Phlebolith: calcified venous thrombi occurring with age, often pelvic veins of women o Rib cartilage calcification: with age, not to be confused with renal or biliary calculi Amorphous, speckled, arc (fig 15.19) Acute abdominal series o Supine: gas pattern, calcification, mass o Prone: gas in rectosigmoid o Upright abdomen: free air, air-fluid level in bowel o Upright chest: free air, pleural effusion Organomegaly (CT, U/S, MRI have replaced assessment of this!) o Only a difference in density between structures will render outlines visible on XR o Indirect evidence by recognizing pathologic displacement of air-filled loops of bowel o Liver Large: displace RUQ bowel to iliac crest or across midline Riedels lobe: tongue-like projection of right lobe = normal o Spleen Normal: 12cm, not projected below 12th posterior rib, as large as left kidney Large: below 12th posterior rib, displaces stomach bubble from midway between spine & abdominal wall towards midline

Chpt 16 How to recognize normal intestinal gas pattern, and 4 abnormal Three key questions o Is their air in rectum or sigmoid? o Dilated loops small bowel? o Dilated loops large bowel? Obstruction Laws of gut o Loops proximal become dilated with air & fluid o Peristalsis continues (except functional) o Loops distal eventually decompress or become airless o Most dilated in mech. Obs: Loops with largest resting diameter before onset (cecum) Loop of bowel just proximal to obstruction Functional ileus o Def: 1+ loops bowel unable to peristalsis (d/t local irritation or inflammation), causing functional ileus o Localized, aka sentinel loops (1-2 loops, usually small bowel >2.5cm) (fig 16.1)

May resemble an early mechanical SBO (look clinically for inflammatory) Causes: cholecystitis, pancreatitis, appendicitis, diverticulitis, ulcer, kidney calculus o Generalized adynamic ileus (all loops large&small, sometimes stomach) (fig 16.2) Air dilates and fluid fills all loops of both small&large bowel Almost always a result of abdominal or pelvic surgery (other: electrolyte imbalance, esp in diabetic ketoacidosis) Mechanical obstruction o Def: a physical, organic obstruction prevents passage o SBO (fig 16.3) Proximal dilation, distal collapse as peristalsis continues or increases Multiple dilated loops of small bowel proximal (>2.5cm) May stack up on each other in step-ladder appearance Numerous air-fluid levels, little or no gas in colon/rectum Causes: postsurgical adhesion**, malignancy, hernia, gallstone, intussusceptions**, IBD Differentiate from functional adynamic ileus (localized) May resemble it early An intermittent (partial) SBO allows some gas to pass obstruction Know history of surgeries adhesions CT may help o LBO (fig 16.7) Proximal dilation, cecum greatest in diameter (law of laplas); distal empty Cecum risk of rupture when >12-15cm Small bowel NOT dilated unless ileocecal vale incompetent Few or no air-fluid levels in obstructed colon Causes: volvulus of cecum or sigmoid**(coffee bean, bird beak) (fig 16.9), malignancy, hernia, diverticulitis, intussusception Mimics mechanical SBO if ileocecal valve incompetent Follow up study: CT, barium per rectum NOT mouth Differentiate from Ogilvies syndrome, often in elderly (fig 16.10) CT no obstructing lesion Syndrome of loss of peristalsis Cause: bedrest, drugs, elderly

Chpt 17 Four common locations of extraluminal air (BEST demonstrated on CT, but XR a start) o Intraperitoneal (free air; pneumoperitoneum) o Retroperitoneal o Bowel wall (pneumatosis intestinalis) o Biliary system (pneumobilia)

Intraperitoneal three major signs o crescentic lucency under diaphragm (fig 17.2) upright film easier to recognize under right hemidiaphragm (fig 17.5) left lateral decubitus if they cant stand o visualize both sides of bowel wall Riglers sign, requiring large amounts of free air to be present (fig 17.7) Overlapping bowel mimics this! (fig 17.8) o visualize falciform ligament falciform ligament sign supine position with large amounts of free air o CAUSES Rupture of air-containing loop of bowel** Peptic ulcer perf Trauma, penetrating Diverticulitis perf, appy perf Carcinoma perf Retroperitoneal o Streaky, linear appearance outlining extraperitoneal structures o Mottled, blotchy appearance o Relativinly fixed position o May outline: psoas, KUB, aorta or IVC, subphrenic tissues o CAUSES: bowel perf** (secondary to IBD, ulcerative dz), trauma, iatrogenic manipulation, foreign body, gas producing infection Bowel wall o Best seen in profile o Linear radiolucency exactly paralleling bowel lumen o En face appears mottled that doesnt change with position o Causes: rare, primary form, pneumatosis cystoides intestinales affecting left colon, cystlike collections in submucosa or serosa more common secondary form: COPD, bowel necrosis (necrotizing enterocolitis, ischemic bowel disease), obstructing lesion (hischsprung, pyloric stenosis, carcinoma) Biliary air o Oen or two tube-like branching lucencies in RUQ, overlying central liver, appearing like major ducts (common, cystic, hepatic) o Causes: may be normal if sphincter of Oddi is open/incompetent sphincterotomy reimplantation of common bile duct surgery

gallstone ileus (fistula) gas-forming pygenic cholangitis