Decubitus Views Research Articles

Radiographic Evaluation of Intussusception: Utility of Left-Side-Down Decubitus View

To assess the incremental value of the left-side-down decubitus view in radiographic evaluation of ileocolic intussusception. The institutional review board approved this retrospective investigation with waiver of informed consent. Between February 24, 2002, and January 25, 2007, 304 studies (300 patients; mean age, 1.3 years; range, 0.1-3.9 years) met the following inclusion criteria: kidney ureter bladder (KUB) and decubitus views obtained, with subsequent proof of diagnosis. Using a consensus approach, two pediatric radiologists evaluated KUB and decubitus views for four variables: (a) discrete mass and (b) small-bowel obstruction (positive criteria); (c) air or stool in ascending colon and (d) cecal air or stool (negative criteria). On the basis of these criteria, each study was graded as negative, positive, or indeterminate for intussusception. Diagnostically determinate studies and the ability to visualize or exclude intussusception were calculated to determine sensitivity and specificity. The difference between proportions was calculated, along with 95% confidence intervals. Agreement between the supine KUB view and supine KUB plus left-side-down decubitus views was tested with the McNemar test. Intussusception was present in 58 of 304 studies (19%). Adding the decubitus view to the KUB view increased the number of determinate studies from 110 of 304 (36.2%) to 205 of 304 (67.4%) (difference, 31.2 percentage points; P < .001). Intussusception was correctly identified with KUB view alone in 35 of 58 studies (60.3%); this value increased to 43 of 58 (74.1%) with KUB plus decubitus views (P = .0215). Intussusception was correctly excluded with the KUB view alone in 63 of 246 studies (25.6%); this increased to 143 of 246 studies (58.1%) with addition of the decubitus view (P < .0001). The addition of decubitus views increased the number of diagnostically determinate studies and increased the ability to diagnose or exclude intussusception. The authors believe that a left-side-down decubitus view should be included in the initial evaluation of patients suspected of having intussusception, particularly when the supine view is diagnostically indeterminate.

The Differential Diagnosis of Right Lower Quadrant Pain: Radiological Clarification

The authors deserve a compliment for their excellent presentation, but a further clarification should be made concerning the necessary radiological studies. The patient with an acute abdomen (the subject of the article) should be studied not with abdominal plain films, but rather with an erect abdominal or left lateral decubitus view, and always with a horizontal beam projection. The patient must maintain this position for five to ten minutes. Only in this way can a perforation of the intestinal tract – e.g., in diverticulitis – be detected by the presence of air under the diaphragm on the right side, and only in this way can fluid levels be seen whose differing heights convey useful information about peristaltic activity. A chest x-ray should always be performed as well, with the patient standing, if possible. Urinary calculi should be sought with a non-contrast-enhanced CT scan as the imaging method of choice; a contrast-enhanced scan can be performed immediately afterward, of course, to answer other questions. Excretion urography is of secondary importance.

Resolution of Residual Pleural Disease According to Time Course in Tuberculous Pleurisy During and After the Termination of Antituberculosis Medication

To assess the resolution of pleural disease in patients with tuberculous pleurisy (TP) during and after antituberculosis medication. An observational, prospective, longitudinal study. University-affiliated general hospital in Seoul, Korea. Chest radiographs of 85 adult TP patients were followed up prospectively from diagnosis to 24 months after the start of medication. The extent of pleural disease, synonymous with the radiographic term, pleural opacity (PO), was evaluated at regular intervals according to a size scale. Additionally, following completion of 6 months of therapy, residual PO (RPO) was determined by either measurement of the widest width of the opacity, if loculated, or at the superior level of the hemidiaphragm. Seventy-seven patients had a PO graded > or = 2 at the initial presentation. At 6, 9, and 24 months, the number of patients with these grades declined. At these time periods, there were 14, 8, and 7 patients, respectively, remaining with this classification. RPO > 10 mm at 24 months was considered indicative of significant residual pleural disease. During the period after 6 months of antituberculosis medication, the number of patients with RPO > or = 10 mm declined from 43 patients at 6 months to 21 patients at 24 months. The presence of loculation on an initial chest decubitus view was associated with significant RPO at 24 months (p = 0.009). In TP patients, improvement of RPO often occurred even after completion of 6 months of antituberculosis medication up to 24 months. A loculated PO at initial presentation, but not initial PO size, was a predictor of significant RPO at 24 months.

Is the Lateral Decubitus Radiograph Necessary for the Management of a Parapneumonic Pleural Effusion?

A pproximately 50% of patients who are admitted to the hospital with community-acquired pneumonia will develop a pleural effusion.1,2 While most parapneumonic effusions will resolve without specific therapy, approximately 10% will become complicated or progress to empyema.3 Because delays in the drainage of these clinically significant effusions have been associated with increased morbidity and mortality,4 prompt detection and accurate characterization of a parapneumonic effusion are important. Guidelines5 based on a consensus conference have comprehensively summarized the literature regarding parapneumonic effusions and have made specific recommendations for their management. Although this document reflects the “state of the art,” as the authors noted, most studies of parapneumonic effusions have been observational, often with a limited numbers of patients. One of the recommendations in the guidelines was that all patients with a parapneumonic effusion should have a chest radiograph performed with a lateral decubitus view.5 This recommendation also was incorporated into the American Thoracic Society guidelines6 for the care of adults with communityacquired pneumonia. The rationale is that if the thickness of the effusion on the lateral decubitus view is 1 cm, the effusion is small enough so that no further intervention is needed.1 While there is good evidence that small effusions resolve without specific therapy,1 the suggestion that a lateral decubitus radiograph is required to determine the appropriate course of action with respect to a parapneumonic effusion appears to have been made without sufficient supporting data. The purpose of this article is to review the indications and usage of the lateral decubitus chest radiograph and demonstrate its limited value in the setting of parapneumonic pleural effusions. Radiographs of the chest made with the patient in the standard erect position usually will not reveal the presence of a pleural effusion 300 to 500 mL in size, as the fluid usually pools in the posterior costophrenic sulcus.7,8 The varying volumes reported may be due to differences in patient size, as a larger individual probably can “hide” a larger volume of fluid than can a smaller individual. The lateral decubitus view was first described by Merlo Gomez and Heidenreich,9 in 1924, as a technique to identify the presence of small pleural effusions. Its first English-language description was by Rigler,7 in 1931, who used this technique to confirm the presence of pleural effusions in a small series of patients despite the absence of a visible effusion using the standard erect views. Subsequently, other investigators demonstrated that the sensitivity of this view can be increased by placing a pillow under the patient’s pelvis, so that the thorax slopes downward away from the lung base.10 By injecting known amounts of fluid into cadavers, in 1973 Moskowitz et al8 demonstrated that effusions as small as 5 to 10 mL could be detected using the lateral decubitus view.

Rapid Pleurodesis for Malignant Pleural Effusions

To determine the feasibility of rapid pleurodesis in patients with malignant pleural effusions in order to reduce hospital length of stay in patients with a limited life expectancy. Prospective case series. Two university hospital programs. Thirty-eight patients with symptomatic pleural effusions associated with malignancy. A 14F catheter was inserted percutaneously into the pleural space after radiographic confirmation of free fluid by lateral decubitus views. Following radiographic confirmation of complete fluid evacuation, a sclerosing agent (ie, talc slurry or bleomycin) was instilled into the pleural space. This was accomplished within 2 h of chest tube insertion, unless the tube was inserted in the evening or if the lung was trapped. After clamping the tube for 90 min, the pleural space was drained for 2 h, after which the chest tube was removed. The intervention was scored as "successful" if no radiographic evidence of fluid reaccumulation was noted at 4 weeks. A "partial successful" score indicated reaccumulation of fluid that did not produce symptoms and did not require repeat pleural drainage of any sort. All other outcomes were scored as "unsuccessful." Forty chest tubes were inserted into 38 patients. Four procedures revealed the presence of a trapped lung and did not result in any attempt at pleurodesis. Five patients who received pleurodesis died in less than 1 month and therefore were not evaluable. Two patients had technical problems with the chest tube and were not evaluable. Of the remaining 29 procedures, drainage procedures with pleurodesis were performed in 27 patients, a complete response was seen in 14 patients (48%), a partial response was seen in 9 patients (31%), and 6 patients (21%) did not respond to pleurodesis. Chemical pleurodesis was completed as an outpatient procedure in only two patients. In one of these, the outcome was unsuccessful. In the remainder, insertion of the chest tube in the evening or additional medical problems necessitated hospital admission, but the entire procedure was completed within 24 h. Chemical pleurodesis can be accomplished with good results in < 24 h in the majority of patients with malignant pleural effusions.

Overview of emergency radiological management of the pregnant patient, especially the traumatized pregnant patient

Both traumatic and nontraumatic acute emergencies are seen in hospitals in women of childbearing age. The effects of radiation are theoretically most deleterious from 10 days after conception until roughly the end of the first trimester. However, there should be no hesitation about performing appropriate emergency imaging studies at any time during pregnancy. If time permits, the presence and age of the fetus should be determined through physical examination, appropriate laboratory studies, and the obtaining of adequate medical historical information. Imaging studies can be roughly classified into two main categories, those with minimal radiation effect and those that may expose the fetus to significant potential ionizing energy. The radiologist must be responsible for the determination of the most appropriate studies needed and in what sequence. Traumatized pregnant patients especially require maternal and fetal monitoring prior to arrival at the hospital and throughout the hospital stay. Fetal demise is a significant risk in case of both minor and major trauma. Maternal survival is the most significant factor in fetal well-being, with a fetal death approaching 80 % in cases of maternal shock and almost 100 % where there is partial or complete abruptio placentae. Properly performed imaging of the pregnant female, where the uterus is not likely to be exposed to ionizing radiation, should be cause little concern. Depending on the clinical presentation, appropriate first images might include a cervical spine, a portable chest film, an abdominal film, and a lateral decubitus view to check for suspected bowel perforation. This should be rapidly followed by fetal and then maternal ultrasonography. Overall, CT may be the best single abdominal study for severe abdominal problems where multiple organ damage is suspected. MRI for neurological disease and carefully monitored of selective vascular embolization for life-threatening abdominal bleeding are other important legitimate imaging studies.

The value of inspiratory-expiratory lateral decubitus views in the diagnosis of small pleural effusions

AIM: To evaluate the usefulness of expiratory lateral decubitus views in the radiological diagnosis of small pleural effusions. MATERIALS AND METHODS: Patients referred for abdominal sonography for various reasons were examined for ultrasonographic features of pleural effusion. From November 1994 until May 1996,36 patients were found to have pleural effusion not exceeding 15 mm in depth and were included in the study. Erect posteroanterior, lateral, and lateral decubitus (in inspiration and expiration) ragiographs were performed in all patients. RESULTS: The mean thickness of fluid was 4.3 mm on inspiratory lateral decubitus radiographs and 7.9mm on expiratory lateral decubitus views ( P<0.005). In 31 of 36 patients (86%) there was a difference in the thickness of the fluid layer as measured in expiratory vs. inspiratory lateral decubitus radiographs. In 16% of patients, the fluid was not visible on inspiratory lateral decubitus projections. CONCLUSIONS: Expiratory lateral decubitus views may be useful for demonstrating small pleural effusions.

A Case of Pulmonary Gangrene Associated with Obstructive Pneumonia Due to Non-small Cell Lung Carcinoma

저자들은 비소세포폐암으로 인한 폐쇄성폐렴에 동반된 림프절종대의 혈관압박에 의해서 발생한 폐괴저를 수술적 치료로 호전시킨 1예를 경험하였기에 문헌고찰과 함께 보고하는 바이다. 【Pulmonary gangrene is a rare complication of severe pulmonary infection in which a pulmonary segment or lobe is sloughed. It is a part of a spectrum of disease in which lung tissue is devitalized(such as necrotizing pneumonia, pulmonary abscess), but apart from them, pulmonary gangrene has more extensive area of necrosis and thrombosis of large vessels plays a prominent role in the pathogenesis. We experienced a case of pulmonary gangrene in 71 year old female obstructive pneumonia patient with non-small cell lung carcinoma. She complained high fever, chill and despite treatment with antibiotics, pneumonia progressed to empyema. At that time chest radiograph showed a large cavity including sloughed lung tissue, freely moving to dependent position at both lateral decubitus view. RML and RLL were resected and compression of pulmonary vessels by enlarged lymph nodes was observed. Defervescence was obtained immediate postoperative period and the patient was discharged after infection control with antibiotics, chest tube drainage. The perivascular lymph nodes dissected during lobectomy were proved to be reactive hyperplasias. We speculated that the carcinoma caused obstructive pneumonia, in turn, resulted in reactive hyperplasia of the draining lymph nodes surrounding the large vessels and finally the lung tissues supplied by them necrotized and sloughed.】

ACCURACY AND EFFICACY OF CHEST RADIOGRAPHY IN THE INTENSIVE CARE UNIT

In summary, the chest radiograph has only moderate accuracy in visualizing opacification caused by cardiopulmonary abnormalities and may be quite nonspecific as to etiology, whereas it has high diagnostic accuracy for detecting malpositioning of tubes and lines. While focal parenchymal abnormalities are usually visualized on chest radiographs, identification of concomitant abnormalities when ARDS or PE already exist is more difficult. Atelectasis, aspiration, pneumonia, pulmonary hemorrhage, pulmonary thromboembolism, atypical cardiogenic edema, asymmetric ARDS, and neoplasms may be indistinguishable. Repeat chest radiographs and different views may be helpful, as the progression and time course of various etiologies can be quite different. On the other hand, Winer-Muram et al found that review of prior radiographs and clinical data did not improve the diagnostic accuracy for either ARDS or pneumonia. Pleural effusions may even be difficult to distinguish from parenchymal processes, particularly when the patient is in the supine position. Additional views with the patient in a different position--semi-erect, decubitus, or cross-table lateral--may be of assistance. In most cases, pneumothorax is readily detected. Additional studies such as the decubitus view occasionally may be necessary for further evaluation when there is uncertainty about the findings. Subcutaneous air is readily visualized radiographically. Pneumomediastinum and interstitial pulmonary emphysema may be more difficult to see. It is well known that CT allows visualization of much smaller abnormal air collections than radiography. Despite this lack of sensitivity and specificity of chest films, studies have shown that up to 65% of daily films in the ICU reveal significant and/or unsuspected abnormalities that may change the patient's diagnosis or management. Based on these results, the consensus opinion of the ACR Expert Panel found that daily chest radiographs are indicated on patients with acute cardiopulmonary problems and those receiving mechanical ventilation. Patients who require cardiac monitoring but are otherwise stable require only an initial admission film. Additional radiographs are indicated only when a new device is placed or when there is a specific question regarding cardiopulmonary status. It is also noteworthy that despite the chest film being the most commonly ordered radiologic examination for inpatients, there are no comprehensive studies evaluating its cost-effectiveness. Although several studies have done a very limited cost accounting of the potential savings by eliminating routine films in the evaluation of specific subsets of patients, overall impact on patient outcome has not been investigated. Thus, a true assessment of cost-effectiveness has yet to be determined.

Colonic pseudo-obstruction: value of prone lateral view of the rectum.

Collection of fluid within the rectum of patients with gas-distended bowel can simulate as obstructive lesion. In 12 patients with suspected distal colonic obstruction on plain radiographs, we obtained 2 additional films comprising a right lateral decubitus view of the abdomen followed by a prone lateral view of the pelvis. Significant gaseous distension of the rectum was achieved in 75% of the 8 patients with pseudo-obstruction. Gaseous filling of the rectum did not occur in any patient with a structural obstructive lesion. In the appropriate clinical setting this approach could exclude the presence of obstruction and avoid unnecessary barium enemas in the majority of patients with colonic pseudo-obstruction.

Delayed tension penumothorax complicating central venous catheterization and positive pressure ventilation

Pneumothorax is the most common complication after central venous catheterization. The diagnosis of pneumothorax may be delayed for hours or days, in some instances because of minimal clinical symptoms or radiographic signs on initial evaluation, or in other instances because of late presentation precipitated by positive pressure ventilation. A case is presented in which a patient developed a tension pneumothorax while under general anesthesia 10 days after central venous line placement. A review of the literature suggests that delayed pneumothorax has an incidence of approximately 0.4% of all central venous access attempts, is much more common after subclavian than internal jugular approaches, especially in difficult or multiple attempts, is asymptomatic in 22%, and results in tension pneumothorax in 22%. End-expiratory upright chest radiographs, the optimal radiographic technique for detection of small pneumothoraces, were obtained in only 19% of reviewed cases. Supine views, the least sensitive radiographic technique, should be carefully reviewed for evidence of basilar hyperlucency, a deep sulcus sign, or a double diaphragm sign. In patients unable to tolerate the upright position, supine views should be supplemented with lateral decubitus, oblique, or cross-table lateral views. Emergency physicians should be aware of the possibility of delayed pneumothorax, as well as optimal radiographic technique for demonstration of small pneumothoraces, and subtle radiographic findings in supine or semirecumbent patients.

51.注腸X線検査におけるデクビタス撮影の有用性について(第23回秋季学術大会一般研究発表予稿)

51.注腸X線検査におけるデクビタス撮影の有用性について(第23回秋季学術大会一般研究発表予稿)

Plain and computed radiography for detecting experimentally induced pneumothorax in cadavers: implications for detection in patients.

Pneumothorax was induced in cadavers to determine the effects of patient positioning and imaging modality (conventional screen-film and computed radiography) on radiographic findings. Chest radiography, with cadavers in the supine frontal, erect frontal, and left lateral decubitus positions, was performed at baseline and after injection of incremental quantities of air into the pleural space. Five radiologists independently interpreted each radiograph. The ability of the radiologists to diagnose pneumothorax varied by cadaver position and depended on volume of air. Overall, the left lateral decubitus view was most sensitive (88%) for diagnosis of pneumothorax, followed by the erect (59%) and supine (37%) views. Receiver operating characteristic curves and multiple repeated measures analysis of variance revealed no statistically significant difference between diagnostic proficiency with conventional screen-film radiography and that with computed radiography. The authors conclude that the lateral decubitus view is superior to the erect and supine views for pneumothorax detection and that conventional and computed radiography perform similarly in pneumothorax detection.

Limiting overhead views in double-contrast colon examinations does not affect diagnostic accuracy.

A prospective study was undertaken to evaluate whether reducing overhead (technician-performed) films in double-contrast colon examinations had any effect on diagnostic accuracy. Only 4 overhead films were obtained routinely: supine, both decubitus, and prone cross-table rectal views. A high detect rate was maintained, comparable to our accuracy when 7 or 8 overhead films were obtained. Our study confirms that with double-contrast colon examinations, the need for overhead films is diminished. A significant decrease in cost, radiation exposure, and examination time can be obtained. We continued to use this method without any noticeable decrease in diagnostic accuracy.

Fever and Pneumopericardium in a Patient with Systemic Sclerosis

A 66-year-old woman was admitted with three days of fever, chills, and pleuritic chest pain. She had a 14-year history of systemic sclerosis with esophageal involvement. Five years prior to admission, she had undergone a hiatal hernia repair for reflux esophagitis, following which she required periodic bougienage for dilation of a distal esophageal stricture. On admission the patient was acutely ill. Her temperature was 37.1°C and blood pressure 78/50 mg Hg. Examination revealed thickened skin, telangiectasias, dullness to percussion and rales at the left lung base, and a loud splashing sound heard diffusely over the precordium corresponding with systole. The ECG showed ST segment elevation in the anterior and lateral leads. Her anteroposterior chest x-ray film (Fig 1) showed a pleural density at the left base, a left lower lobe infiltrate, and an air-fluid level in the esophagus (arrow). A decubitus view (Fig 2) demonstrated pneumopericardium (arrow), an air-fluid interface in the esophagus (open arrow), and small bilateral free-flowing pleural effusions (arrowheads). Figure 2 View Large Image Figure Viewer

The contralateral decubitus chest film

The radiology and emergency medicine literature have emphasized the value of the cross-table decubitus chest film taken with the hemithorax containing the suspected pathology in the dependent position. When used in conjunction with the upright chest film, the contralateral decubitus film (with the side of interest up) often reveals more information than does the film with the side of interest dependent. The unsuspected bilaterality of pleural effusion, especially when subpulmonic, often is revealed, as is pathology in the lung base that is obscured by large effusion or cardiomegaly. Masses, cavities, and areas of consolidation may become apparent. Especially important in pediatric patients, vascular structures can be distinguished from infiltrate. The contralateral decubitus film should be obtained when examinations in other positions have yielded equivocal results, rather than repeating an examination. This avoids unnecessary radiation exposure and is cost effective. Because of their complementary nature, in many cases both decubitus views should be obtained.

Computed Tomography of Lung Abscess and Empyema

Lung abscess and empyema can often be distinguished on plain radiographs. Sometimes, oblique or decubitus views may be necessary in order to demonstrate the more specific conventional radiographic features--the shape of the lesion and its relationship to the chest wall. In seriously ill patients, special positioning may be impossible. CT may be easier to perform than special views in some ill patients. In many cases of suppurative disease, both lung and pleura may be involved, and pleural disease in the presence of lung disease is easily missed on plain radiographs. Furthermore, infections located at the periphery or at the apices of the thorax are difficult to define with conventional imaging. CT with cross-sectional images and unequalled density resolution delineates the lung-pleura interface and the periphery and apices of the lung. With CT, lung abscess and empyema show statistically significant differences in shape--round (abscess) or lenticular (empyema); the presence of separation of pleural layers (empyema); the presence of lung compression (empyema); the presence of acute (abscess) or obtuse (empyema) chest wall angles; and wall characteristics--thick, nonuniform, and irregular (abscess) or thin, uniform, and smooth (empyema). Few lesions demonstrate all of these features; however, sufficient information may be obtained from CT to permit a confident diagnosis of lung abscess or empyema. Thus, CT helps in the evaluation of suppurative diseases. CT provides diagnostic information not available from conventional radiographs in 47 per cent of cases, and in 34 per cent of cases, CT gives more accurate delineation of the extent of disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Left lateral decubitus sonography of gallstones in the contracted gallbladder.

A prospective study of the accuracy in diagnosing gallstones using ultrasonography in the absence of a fluid-filled gallbladder was done over a 20 month period; 91 patients were studied. A focal echo complex with acoustic shadowing was shown to be a highly reliable criterion for diagnosing gallstones in a contracted gallbladder when (1) it was demonstrated on longitudinal, transverse, and left lateral decubitus views, and (2) the configuration of the echo complex remained the same.

Erect scanning of pancreas using a gastric window.

A technique that can offer improved ultrasonic visualization of the pancreas is reported and evaluated. One hundred subjects were scanned in an erect sitting position with fluid-filled stomachs ("erect gastric window" technique). Conventional supine scans were initially performed in all cases; oblique, semierect, decubitus, prone, and standing positions with and without fluid-filled stomach were also evaluated. Compared with supine scans, the "erect gastric window" technique, occasionally supplemented by semierect, oblique, or decubitus views, provided significantly improved visualization of the pancreas in 93% of subjects. The nonvisualization rate was reduced from 19% to 1%.

Assisted expiratory chest radiography: an effective technique for the diagnosis of foreign-body aspiration.

Chest radiography is a sensitive indicator of bronchial obstruction by aspirated foreign bodies. In young children and infants, adequate expiratory studies are easily obtained when gentle pressure is applied to the epigastrium with a lead-gloved hand. This technique is preferable to fluoroscopy, decubitus views, and radionuclide perfusion imaging for the diagnosis of partial bronchial obstruction.