Erect Chest Radiograph Research Articles

Ruptured Splenic Abscess with Pneumoperitoneum: A Rare Presentation

Splenic abscess is a rare entity encountered during clinical practice, with a high mortality rate. Formation of gas in splenic abscess is usually localized to the left upper quadrant of the abdomen. Here we report a case where the splenic abscess ruptured and presented with generalized peritonitis. The erect chest radiograph showed free air under the right dome of the diaphragm, thus masquerading a hollow viscera perforation (most common cause of pneumoperitoneum).

EP.FRI.398 Diverticular Disease Patient Presenting with Acute Abdominal Pain, Guidelines and Management

Abstract Aim Diverticular disease of the sigmoid colon is a common condition in Western society, 10-25% will develop an acute episode of diverticulitis, Since Hinchey’s traditional classification for perforated diverticulitis in 1978, several modifications and new grading systems have been presented to display a more contemporary overview of the disease Methods 100 patients diagnosed with acute diverticulitis admitted to the surgical unit in NMUH starting from 1/1/2019 (the first 100 patients were chosen - they attended over a period of 6 months) Data were checked for all patients from the patients' notes and electronic hospital systems for as compared to the: “Acute Diverticulitis Management Algorithm”, provided on the NMUH intranet since April 2015. Results 10% of patients Had pain and tenderness in an abdominal quadrant other than left iliac fossa. Standard investigations including WCC, CRP & erect chest radiograph were done to all patients. 84% of patients were diagnosed with CT scan while the rest were diagnosed clinically. 96% of patients had colonoscopy appointments while 4% had CT colonography appointments. There was no mention of Hinchey grade, despite cases were managed according to this classification. Conclusions There was a good degree of commitment to the management algorithm in some parts, like blood tests and antibiotic prescription, however other parts were not adhered to like the Hinchey's classification documentation for each case. There is a need for more clinical and management related classification system of acute diverticulitis, some classifications were proposed.

Phase 3 of COVID-19: Treat your patients and care for your radiographers. A designed projection for an aware and innovative radiology department

Abstract Since the spread of Covid-19 outbreak, healthcare workers (HCWs) have faced an unprecedented and unpredictable situation on the frontlines. The aim of this document is therefore to provide useful and operative recommendations to radiographers who perform imaging services, such as chest X-ray (XR) and Computer Tomography (CT) scans to three types of patients: negative, suspected or suffering from Severe Acute Respiratory Syndrome by Coronavirus (SARS-CoV-2). It is paramount to design two different paths’ layouts for patients entering the Radiology Department. One path should care for the confirmed and suspected SARS-CoV-2 patients, whereas the other path should be for negative patients. A setting envisaging two radiographers is highly recommended when managing Covid-19 patients. One radiographer fully-equipped with proper personal protective equipment (PPE) should deal with the patient in the scanning or x-ray room. The second one should stay in the console room wearing essential PPE. Disinfection plays a crucial role in reducing the risk of disease transmission. Moreover, having clear protocols is key to ensure personal safety and avoid cross-infections. Taking care of patients and HCWs, such as radiographers, is crucial to minimize the risk of disease transmission. Within a Radiology Department, different designed pathways should be taken into consideration both for everyday and epidemic/pandemic healthcare situations. Though Covid-19 pandemic has been a harsh experience in terms of world health and care systems for patients and health professionals - being radiographers among the most involved - we must not miss this chance to learn from what happened. There is the need to address wider causes through learning and in order to prevent failures. The distinction between passive learning (where lessons are identified but not put into practice) and active learning (where those lessons are embedded into an organization’s culture and practices) is crucial in understanding why truly effective learning so often fails to take place.

Initial data from an experiment to implement a safe procedure to perform PA erect chest radiographs for COVID-19 patients with a mobile radiographic system in a “clean” zone of the hospital ward

IntroductionWith the current Covid-19 pandemic, general wards have been converted into cohort wards for Covid-19 patients who are stable and ambulant. A 2-radiographer mobile radiography team is required to perform bedside Chest X-rays (CXR) for these patients. Hospital guidelines require both radiographers to be in full Personal Protective Equipment (PPE) throughout the image acquisition process and the mobile radiographic unit needs to be disinfected twice after each case. This affects the efficiency of the procedure and an increase usage of limited PPE resources. This study aims to explore the feasibility of performing mobile chest radiography with the mobile radiographic unit in a “clean” zone of the hospital ward. MethodsAn anthropomorphic body phantom was used during the test. With the mobile radiographic unit placed in a “clean” zone, the phantom and the mobile radiographic unit was segregated by the room door with a clear glass panel. The test was carried out with the room door open and closed. Integrated radiation level and patient dose were measured. A consultant radiologist was invited to review and score all the images acquired using a Barco Medical Grade workstation. The Absolute Visual Grading Analysis (VGA) scoring system was used to score these images. ResultsA VGA score of 4 was given to all the 40 test images, suggesting that there is no significant differences in the image quality of the images acquired using the 2 different methods. Radiation exposure received by the patient at the highest kV setting through the glass is comparable to the regular CXR on patient without glass panel at 90 kV, suggesting that there is no significant increase in patient dose. ConclusionThe result suggests that acquiring CXR with the X-ray beam attenuating through a glass panel is a safe and feasible way of performing CXR for COVID-19 patients in the newly converted COVID wards. This will allow the mobile radiographic unit as well as one radiographer to be completely segregated from the patient. Implications for practiceThis new method of acquiring CXR in an isolation facility set up requires a 2-Radiographer mobile radiography team, and is applicable only for patients who are generally well and not presented with any mobility issues. It is also important to note that a clear glass panel must be present in the barriers set up for segregation between the “clean” zone and patient zone in order to use this new method of acquiring CXR.

Pancreatic Pseudocyst with Mediastinal Extension Presenting as Pseudo-Kirklin Sign—Multimodality Imaging

AbstractA mass lesion of the gastric cardia or fundus causing an alteration in the normal regular, translucent gastric fundal air shadow on a frontal erect chest radiograph is referred to as “the Kirklin sign.” Here we present “Pseudo-Kirklin sign” observed on the frontal radiograph of a 46-year-old male patient due to a soft tissue shadow/contour deformity of the fundal gas shadow caused by pseudocyst of the pancreas. We evaluated the patient using plain radiography, contrast enhanced computed tomography, magnetic resonance imaging, and endoscopic ultrasound (EUS) with the cyst drained under EUS guidance. So far only two cases of mediastinal pseudocysts have been drained successfully by EUS-guided aspiration.

Chilaiditi’s Syndrome—What Every Endoscopist Should Know

Chilaiditi’s syndrome is a rare and often asymptomatic anomaly, typically found as an incidental radiographic sign (gas under the diaphragm) due to hepato-diaphragmatic interposition of the transverse colon. We report a case of Chilaiditi’s syndrome following colonoscopy presenting with severe abdominal pain, dyspnoea and radiograph findings similar to the presence of bowel perforation (appearance of gas under the hemidiaphragm on erect chest radiograph). Computed tomography (CT) evidence of Chilaiditi’s sign prevented unnecessary laparotomy.

Chilaiditi’s sign: hepatodiapragmatic interposition of the small intestine

Chilaiditi’s sign or hepatodiaphragmatic interposition of bowel seen on an erect chest radiograph can mimic pneumoperitoneum. The presence of plicae circulare or haustrations is necessary to differentiate this condition from pneumoperitoneum. When this radiological sign is accompanied by a broad range of gastrointestinal symptoms, the condition is known as Chilaiditi’s syndrome. In a majority of the cases, Chilaiditi’s syndrome is managed symptomatically. We present a case of incidentally detected Chilaiditi’s sign in a 73-year-old asymptomatic male.

A seizure-induced T8 burst fracture re-presenting as an acute abdomen

A male aged 44 years presented to the emergency department with a 1-week history of intermittent right-sided abdominal pain radiating to the midline. Examination demonstrated a tender right upper quadrant...

Perforated peptic ulcer - an update.

Peptic ulcer disease (PUD) affects 4 million people worldwide annually. The incidence of PUD has been estimated at around 1.5% to 3%. Perforated peptic ulcer (PPU) is a serious complication of PUD and patients with PPU often present with acute abdomen that carries high risk for morbidity and mortality. The lifetime prevalence of perforation in patients with PUD is about 5%. PPU carries a mortality ranging from 1.3% to 20%. Thirty-day mortality rate reaching 20% and 90-d mortality rate of up to 30% have been reported. In this review we have summarized the current evidence on PPU to update readers. This literature review includes the most updated information such as common causes, clinical features, diagnostic methods, non-operative and operative management, post-operative complications and different scoring systems of PPU. With the advancement of medical technology, PUD can now be treated with medications instead of elective surgery. The classic triad of sudden onset of abdominal pain, tachycardia and abdominal rigidity is the hallmark of PPU. Erect chest radiograph may miss 15% of cases with air under the diaphragm in patients with bowel perforation. Early diagnosis, prompt resuscitation and urgent surgical intervention are essential to improve outcomes. Exploratory laparotomy and omental patch repair remains the gold standard. Laparoscopic surgery should be considered when expertise is available. Gastrectomy is recommended in patients with large or malignant ulcer.

Effectiveness of breast fixation to reduce migration of the tip of a totally implantable venous access port in women.

To evaluate effectiveness of breast fixation to reduce migration of the catheter tip of a totally implantable venous access port (TIVP) in women. TIVPs were placed in 129 women via the right axillary vein from July 2012 to December 2014, with a final study population of 118 patients (mean age, 55.3 ± 13.8 years; range, 21-91 years). The patients were divided into two groups according to breast fixation during TIVP placement. A total of 56 patients received TIVP placement without breast fixation (Group 1); the remaining 62 received TIVP placement in the supine position after fixation of the ipsilateral breast on the abdominal wall in the sitting position (Group 2). Medical records were retrospectively reviewed for age, weight, height, body mass index, and underlying malignancy. We evaluated the difference in distance ratios between the port chamber and the catheter tip on supine chest and erect chest radiographs, respectively. Statistical analysis was performed using Student's t test. Differences in all parameters between Group 1 and Group 2 were not statistically significant. Mean distance ratio between the port chamber and the catheter tip was 1.95 ± 0.97 in Group 1 and 1.33 ± 0.59 in Group 2. Differences in distance ratios between the port chamber and the catheter tip were statistically significant between Group 1 and Group 2 (p = 0.001). Breast fixation seems to be effective in reducing migration of the port chamber and catheter tip with position changes in female patients during TIVP placement.

Dose Intraoperative Fluoroscopy Precisely Predict Catheter Tip Location via Superior Vena Cava Route?

Adequate catheter tip location is crucial for functional intravenous port and central venous catheter. Numerous complications were reported because of catheter migration that caused by inadequate tip location. Different guidelines recommend different ideal locations without consensus. Another debate is actual movement of intravascular portion of implanted catheter. From literature review, the catheter migrated peripherally an average of 20 mm on the erect chest radiographs. In this study, we want to verify the actual presentation of catheter movement within a vessel and try to find a quantitative catheter length model to recommend.From March 2012 to March 2013, 346 patients were included into this prospective cohort study. We collect clinical data from medical record and utilized picture archiving and communication system to measure all image parameters. Statistical analysis was utilized to identify the risk factors for catheter migration.The nonmigration group had 221 patients (63.9%); 67 (19.4%) patients were classified into the peripheral migration group; and 58 (16.8%) patients were classified into the central migration group. Patients with short height (P = 0.03), larger superior vena cava (SVC) diameters at the brachiocephalic vein confluence site (P = 0.02), and longer implanted catheter length (P = 0.0004) had greater risks for central migration. We utilized regression curve for further analysis and height (centimeters)/10 had moderate correlation distances from the entry vessel to the carina.Although intravascular movement of catheter was exist in implanted catheter, the intraoperative fluoroscopy could provide accurate catheter tip location in 63.9% patients. Additional length of catheter implantation seems unnecessary in 80.6% patients. Patients with short height, larger SVC diameters at the brachiocephalic vein confluence site had greater risk for catheter central movement. Height/10 may be consider as reference length of implantation for inexperience surgeon and precise implantation length could be adjust under guidance of fluoroscopy.

Gastric volvulus – An uncommon cause of upper gastrointestinal bleed

Gastric volvulus is an uncommon condition which is difficult to diagnose and treat. There are predominantly two types of Gastric volvulus, Oraganoaxial and Mesenteroaxial. The most common cause of gastric volvulus is secondary to hiatus hernia. The diagnosis is suspected when erect chest radiograph images show a high airfluid level in the chest. Gastric volvulus is a life threatening emergency, because it may lead to strangulation of stomach and perforation. Copyright © 2014, Indian Journal of Medical Specialities. Published by Reed Elsevier India Pvt. Ltd. All rights reserved.

Anesthetic management of a case of spontaneous rupture of diaphragm.

Sir, A 58-year-old male patient presented with a history of sudden onset of the left upper quadrant pain and vomiting from 6 days following the lifting of bucket filled with water. He also had a history of the left lower chest pain on inspiration, dyspnea on lying supine, decrease appetite and constipation. Vitals were almost normal at admission. Oxygen saturation was 90%. On auscultation air entry was absent over left lower hemithorax. Routine blood tests were normal. Arterial blood gas showed respiratory alkalosis with mild hypoxemia (pH 7.50, pCO2 30 mmHg and pO2 64 mmHg). Electrocardiogram showed “t” wave inversion in leads V1, V2 and V3. A plain erect chest radiograph showed upward shifting of the left side of hemidiaphragm, air filled shadow of stomach occupying lower half of left hemithorax, compression of the left lung, shifting of the trachea and mediastinal structures to the right side [Figure 1]. In the operating room, standard anesthesia monitors were attached. A rapid sequence induction (RSI) of anesthesia was done with thiopentone, succinylcholine, and fentanyl. Due to nonavailability of double lumen tube trachea was intubated with number 8.0 standard endotracheal tube (ETT) that was intentionally inserted in the right main bronchus and was fixed at 26.0 cm. A pressure controlled mode was initiated. Anesthesia was maintained on oxygen in the air and isoflurane. Laparotomy via midline approach revealed a tear of approximately 5 cm at the lateral side of left hemidiaphragm. Stomach was pulled down through the rent along with gangrenous part of omentum. Gastropexy was done and diaphragm tear was repaired. Gangrenous part of omentum was resected out. ETT was withdrawn to 22 cm at upper incisor and bilateral air entry was confirmed. Chest drain was placed. At the end of surgery, patient was extubated in the operating room with acceptable vital parameters. Figure 1 X-ray chest posteroanterior view showing left diaphragmatic hernia Spontaneous rupture of the diaphragm is extremely rare with limited literature. Spontaneous rupture can be due to violent cough,[1,2] during vaginal delivery[3] physical activity,[2] violent vomiting and defecation.[4] Sudden and violent Valsalva maneuver with increased intraabdominal pressure is main denominator in these cases.[5] Diagnosis is difficult due to nonspecific clinical presentation such as upper quadrant abdominal pain, vomiting, and constipation.[6] This is mostly associated with dyspnea, tachycardia and hypotension. Chest radiograph may help in diagnosis, but has poor sensitivity and specificity. Radiographic finding includes herniation of abdominal viscera into the thoracic cavity, compression of ipsilateral lung and displacement of mediastinum to the opposite side. “Collar sign” is the presence of a large bulla between the abdomen and the chest, with a constriction at the diaphragmatic level is specific of a diaphragmatic defect.[5] Early complications may include strangulation of intestine that can terminate in rupture and gangrene formation. Peritonitis and pleural effusion may be the sequel. Early intervention includes oxygenation, correction of fluid deficit, gastric decompression etc. Emergent surgical intervention is usually required in view of high mortality and morbidity. The causative factor for diaphragm rupture would be the raised intraabdominal pressure during lifting of a heavy object. Other possible etiologies like congenital diaphragmatic hernia or ischemic process was ruled out by intraoperative findings. Anesthetic management of these patients is quite challenging in view of an emergency nature of surgery with inadequate time to patient optimization, unstable hemodynamics, high probability of hypoxemia and rapid desaturation, full stomach, fluid deficit, electrolyte imbalance and need for one lung ventilation. These patients often require the securing of wide bore intravenous access or central venous cannulation, beat to beat blood pressure monitoring if hemodynamically unstable. RSI in these patients may cause rapid desaturation because of already decreased functional residual capacity. During mechanical ventilation, lung protective strategy should be applied with low tidal volume and positive end expiratory pressure. Postoperatively, patient can be extubated in the operating room if vital parameters allow. Grossly ruptured and hemodynamically unstable patient should be allowed to ventilate postoperatively. Adequate analgesia (epidural analgesia) in the postoperative period can help in early recovery. Patient controlled analgesia can be used if epidural was placed.

An evaluation of embolisation in the management of haemorrhage from traumatic solid organ injury at a level 1 major trauma centre

An evaluation of embolisation in the management of haemorrhage from traumatic solid organ injury at a level 1 major trauma centre

Are plain abdominal and erect chest radiographs still diagnostically useful, cost-effective and relevant in acute admissions in modern surgical practice?

Are plain abdominal and erect chest radiographs still diagnostically useful, cost-effective and relevant in acute admissions in modern surgical practice?

An unusual presentation of recurrent pneumonia

In October, 2010, a 20-year-old man was referred to us after having been admitted to hospital four times with community acquired pneumonia since the age of 16 years. His recurrent symptoms included a productive cough, lethargy, fever, night sweats, and rigors. Apart from child-hood asthma, he had no important medical history of respiratory illness. He was a life-long non-smoker and denied illicit drug use. Auscultation of the chest showed equal air entry to the lung fi elds with mild crepitations in the left lower zone posteriorly. Erect chest radiography showed multiple cystic lesions in the left lower lobe posteriorly with crowding of bronchovascular markings (fi gure A). CT of the chest showed a systemic artery feeding a left lower lobe pulmonary sequestration (fi gure B). The feeding artery originated from the common hepatic artery before passing through the oesophageal hiatus into the thorax. Aberrant venous drainage from the sequestration was not identifi ed and a diagnosis of intralobar pulmonary sequestration was made.Our patient had a bronchoscopy with normal fi ndings, followed by a left posterolateral thoracotomy. Intra-operatively, the pulmonary sequestration was found to be strongly adherent to the diaphragm. An aberrant systemic artery was seen rising through the oesophageal hiatus and was suture ligated and divided. No other aberrant arteries or veins were identifi ed. The sequestered lung was resected by a routine left lower lobectomy. He had an unremarkable recovery and was discharged home on the fourth day postoperatively. Macroscopic pathological

My Patient is Short of Breath: Have They Got a Pneumothorax?

Clinical diagnosis of pneumothorax in the emergency department (ED) resuscitation room can be difficult and in certain circumstances chest radiography is either impractical or the delay is unacceptable. The diagnosis must also be considered in other clinical areas such as critical care, theatres, respiratory units and acute medical units. Erect chest radiography is the standard first-line diagnostic test for pneumothorax in the ED, but the sensitivity is low (59–81%). For many patients in ED, critical care and theatre, an erect chest radiograph is not possible as the patient must remain supine. The sensitivity for a supine chest radiograph has been reported as being 45–75%. Ultrasound has been shown to be more sensitive than chest radiography in the diagnosis of pneumothorax in certain settings. This paper outlines the evidence for ultrasound in the diagnosis of pneumothorax in the point of care setting; it describes the technique and discusses the clinical application of this imaging modality.

Ectopic gastric mucosa in “ectopic” Meckel’s diverticulum

A previously healthy 11-year-old boy presented with an acute onset of hematochezia, right abdominal pain and syncope. On admission, he was found to be hypotensive with a blood pressure of 90/60 mmHg, and tachycardic with a pulse rate of 100 beats/min. The hemoglobin level was 8.1 g/dL. The boy was promptly resuscitated responding with a blood pressure of 110/70 mmHg, and a pulse rate of 80 beats/min. The physical examination was otherwise unremarkable. The abdomen was soft with no guarding or rebound tenderness. The rectal examination was unremarkable apart from traces of fresh blood. The platelet count of 307 9 10/L was normal, and he did not have a coagulopathy. Erect chest radiograph and abdominal radiograph studies were unremarkable with no evidence of pneumoperitoneum or other abnormality. An abdominal ultrasound scan was normal with no intussusception detected. A Meckel’s scan was performed to evaluate for a Meckel’s diverticulum containing ectopic gastric mucosa. After intravenous administration of 155 MBq (4.19 mCi) of Technetium pertechnetate, images of the abdomen were acquired with a dual-head gamma camera (ECAM, Siemens, Erlangen, Germany). The Meckel’s scan showed an abnormal focus of tracer activity in the right upper abdomen that appeared early with gastric activity, indicative of ectopic gastric mucosa (Fig. 1, arrow). The abnormal tracer was persistent and unchanged in position over 60 min, distinguishing it from physiological bowel activity. Despite the unusual location, a Meckel’s diverticulum containing ectopic gastric mucosa was thought probable. The boy underwent a laparoscopy. Intraoperatively, a 4 cm long inflamed Meckel’s diverticulum was found arising from the ileum, approximately 15 cm from the ileocecal junction, and this was located ‘‘ectopically’’ in the right hypochondrium (Fig. 2, arrow). Dark bluish colored blood from a recent hemorrhage was seen through the bowel wall (Fig. 2, arrowheads). The Meckel’s diverticulum was resected, and histology confirmed that the diverticulum contained the gastric mucosa. The patient recovered swiftly after the surgery. A Meckel’s diverticulum is the most common congenital abnormality of the gastrointestinal tract, and is found in 1–3% of the population [1]. It is a result of a failure of regression of the omphalomesenteric duct, and is frequently located within 100 cm proximal from the ileocecal valve, and hence, symptoms typically involved the lower abdomen [1]. It is most frequently asymptomatic, with symptoms being present in approximately 25% of the cases [2, 3]. The symptoms arise from the complications of a Meckel’s diverticulum, which include bleeding, intestinal obstruction, diverticulitis, vesicodiverticular fistula and tumor [2, 3]. Bleeding secondary to ectopic gastric mucosa is the most common complication of a Meckel’s diverticulum, and is most often seen in the pediatric population, particularly in patients younger than 2 years of age [3]. In adults, the most common complication of a Meckel’s diverticulum is intestinal obstruction, which may be secondary to intussusception, volvulus or internal herniation S.-J. Lu (&) A. Sinha Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore e-mail: suat_jin_lu@yahoo.com

Vascular Pedicle Width on Chest Radiograph as a Measure of Volume Overload: Meta-Analysis

IntroductionVascular pedicle width (VPW), a measurement obtained from a chest radiograph (CR), is thought to be an indicator of circulating blood volume. To date there are only a handful of studies that demonstrate a correlation between high VPW and volume overload, each utilizing different VPW values and CR techniques. Our objective was to determine a mean VPW measurement from erect and supine CRs and to determine whether VPW correlates with volume overload.MethodsMEDLINE database, Web of Science, and the Cochrane Central Register of Controlled Trials were searched electronically for relevant articles. References from the original and review publications selected electronically were manually searched for additional relevant articles. Two investigators independently reviewed relevant articles for inclusion criteria and data extraction. Mean VPW measurements from both supine and erect CRs and their correlation with volume overload were calculated.ResultsData from 8 studies with a total of 363 subjects were included, resulting in mean VPW measurements of 71 mm (95% confidence interval [CI] 64.9–77.3) and 62 mm (95% CI 49.3–75.1) for supine and erect CRs, respectively. The correlation coefficients for volume overload and VPW were 0.81 (95% CI 0.74–0.86) for both CR techniques and 0.81 (95% CI 0.72–0.87) for supine CR and 0.80 (95% CI 0.69–0.87) for erect CR, respectively.ConclusionThere is a clinical and statistical correlation between VPW and volume overload. VPW may be used to evaluate the volume status of a patient regardless of the CR technique used.

Erect chest radiograph in the setting of the acute abdomen: essential tool or waste of resources and unneccesary?

Erect chest radiograph in the setting of the acute abdomen: essential tool or waste of resources and unneccesary?