670 Section 4 X-rays

STRAIGHT X-RAY OF CHEST/ABDOMEN WITH FREE GAS UNDER

BOTH DOMES OF DIAPHRAGM (FIGS 17.1 TO 17.3).

Figure 17.1: This is a straight X-ray of chest along with upper part of abdomen showing
free gas under both domes of the diaphragm and there is a ground glass appearance in the
abdomen (Courtesy: Prof Bitan Kumar Chattopadhyay, IPGME & R, Kolkata)

Figure 17.2: Similar X-ray—Note huge amount of free gas under both domes of diaphragm
 Chapter 17 X-rays 671

Figure 17.3: Similar X-ray—Note chink of free gas under both domes of
diaphragm

What is this radiological appearance suggests?

This appearance is due to free gas and fluid in the peritoneal cavity.
What are the causes of such X-ray appearance?
1. Perforation of hollow viscera containing gas :
• Peptic ulcer perforation—gastric or duodenal
• Perforation of malignant gastric ulcer
• Small gut perforation due to typhoid ulcer, tubercular ulcer, Crohn's disease.
• Large gut perforation due to tubular ulcer, Crohn’s or ulcerative colitis.
− Blunt trauma abdomen causing perforation or transaction of small or large gut.
2. Penetrating injury abdomen causing peritoneal penetration, with or without underlying
visceral injury.
3. Bullet injury abdomen—with peritoneal penetration and with or without underlying hollow
viscus injury.
4. Following laparoscopic procedure or following abdominal operation—due to entrapment
of carbon dioxide gas or air.
5. Following tubal insufflation test for tubal patency.
Why you do not find free gas under diaphragm in appendicular perforation?
Usually obstructive type of appendicitis leads to perforation. The lumen of appendix contains
very little amount of gas. So there is no free gas under diaphragm in appendicular perforation.
However, if there is perforation at the base of the appendix involving the cecal wall, there may
be free gas under both domes of diaphragm.
How do you explain the ground glass appearance in X-ray?
The ground glass appearance is due to fluid in peritoneal cavity. There may be air fluid level
below the domes of diaphragm.
Do you find free gas under the diaphragm in all cases of peptic perforation.
No. In 60–70% cases of peptic perforation there will be free gas under the diaphragm, and in the
remaining there may be no free gas under the diaphragm.
 Chapter 17 X-rays 675

PLAIN X-RAY OF ABDOMEN. MULTIPLE AIR FLUID LEVELS (FIGS 17.4 TO 17.6)

Figure 17.4: This is a straight X-ray of abdomen with lower part of chest and upper part of pelvis taken in
erect posture showing multiple air fluid levels. The distended gut loops are situated in the central part of
the abdomen and are arranged in a step ladder fashion. The upper loops are showing presence of valvulae
conniventes which are closely packed and complete suggesting these to be distended jejunal loops. The
distended gut loops in right iliac fossa region do not show presence of any valvulae conniventes and appear as
characterless suggesting these to be distended ileal loops. This appearance is suggestive of acute small bowel
obstruction (Courtesy: Dr QM Rahaman, Registrar, WBUHS, Kolkata)

Figure 17.5: Similar X-ray as in Figure 17.4 showing multiple air fluid levels. The gas filled intestinal loops
are central in location arranged in a stepladder fashion. Most of the distended loops do not valvulae
conniventes and appear characterless, suggesting these to be distended ileal loops. This appearance is
suggestive of acute small bowel obstruction
676 Section 4 X-rays

Figure 17.6: Similar X ray—Showing multiple air fluid levels.

The air fluid filled loops are central in location, arranged in
a stepladder pattern. Note the characterless appearance
(absence of valvulae conniventes) suggesting these to be
ileal loops (Courtesy: Dr Partha Bhar, IPGME & R, Kolkata)
What is the diagnosis?
This is likely to be a X-ray of patient with small bowel obstruction.
Why do you say these gas filled loops are jejunal loops?
These gas filled intestinal loops are likely to be jejunal loops because of following characteristics:
„ These gas filled loops are centrally located in the abdomen.
„ They are arranged in a stepladder pattern.
„ There are closely packed valvulae connivantes indicated by white lines in the gas filled gut.

What are the characteristics of gas filled ileal loops?

„ These are also central in location and may have step ladder pattern of arrangement.
„ But the valvulae conniventes if present are very sparse and incomplete.
„ The gas filled ileal loops are typically described as characterless.
What are the characteristics of colonic gas shadows?
The characteristics of colonic gas shadows are:
„ The colonic gas shadows are situated more peripherally.
„ There are haustrations in the walls. These are incomplete mucosa folds in the walls placed
at different levels.
Which X-ray is important for evaluation of patient with acute intestinal obstruction?
A supine abdominal film gives better delineation of the gas filled gut loop and an erect film is
not required routinely.
How many fluid levels in abdomen X-ray may be regarded as normal?
In adults two inconstant fluid levels—one at duodenal cap another at terminal ileum may be
regarded as normal.
In infants few fluid levels (2–4) in small gut may be regarded as normal.
682 Section 4 X-rays

Alternatively, the decompression may be done by an enterotomy and using a Savage’s

decompressor, but the risk of contamination is very high.
Large gut decompression may be done by inserting a needle obliquely through the tenia
coli and suction under low pressure. The site of the needle puncture should be oversewn with
a seromuscular suture using 3-0 polyglactin.

SIGMOID VOLVULUS (FIGS 17.7 AND 17.8)

Figure 17.7: This is a straight X-ray of abdomen along with upper part of the pelvis taken in erect posture
showing a hugely distended large gut loop extending from the pelvis to the upper abdomen. Two loops
are distinctly seen with outer borders and an intervening wall formed by inner walls of the sigmoid colon.
All these distended gut walls are seen converging towards the pelvis. This appearance is suggestive of
large bowel obstruction due to sigmoid volvulus

Figure 17.8: Similar X-ray omega shaped distended large gut loop. All three lines converging towards the
pelvis suggesting sigmoid volvulus (labeling)
 Chapter 17 X-rays 687

„ In presence of gangrene or perforation—resection and exteriorization of the proximal

segment is safe.
„ In absence of gangrene or perforation—tube cecostomy is ideal for decompression.

RADIOPAQUE GALLSTONE AND KIDNEY STONE (FIG. 17.9)

Figure 17.9: This is a plain X-ray of abdomen with upper part of pelvis showing
multiple radiopaque shadows in the right paravertebral region below the 12th rib
which appears closely packed. Apart from these there is another dense staghorn type
of radiopaque shadow in the right kidney region

What is your diagnosis?

This appearance suggests radiopaque gallstones and kidney stone.
What percentage of gallstone and kidney stones are radiopaque?
About 10% gallstones are radioopaque and about 90% kidney stones are radiopaque.
What are the D/D of a radiopaque shadow in this region?
„ Kidney stone
„ Gallstones
„ Pancreatic calculi
„ Foreign body
„ Fecolith
„ Phleboliths
„ Calcified lymph node
„ Calcified renal tuberculosis
„ Calcified adrenal gland
„ Chip fracture of a transverse process of vertebra or calcification of costal cartilage.
How will you confirm your diagnosis?
„ I will take a lateral view
• Gall stone lies anterior to the vertebral body
• Kidney stone lies posterior to the vertebral body or overlaps the vertebral body
„ Confirmation will be by an ultrasonography.
 Chapter 17 X-rays 689

RADIOPAQUE KIDNEY STONES AND BLADDERSTONE (FIGS 17.10 AND 17.11)

Figure 17.10: This is a plain X-ray of kidney, ureter and part of

the bladder region showing multiple radiopaque shadows in
the left kidney region (Courtesy: Dr Soumen Das, IPGME & R,
Kolkata)

Figure 17.11: This is plain X-ray of kidney, ureter and bladder

region showing a oval radiopaque shadow in the right half of the
pelvis (Courtesy: Dr Subhasis Saha, IPGEM & R, Kolkata)
692 Section 4 X-rays

„ The larger stone needs to be fragmented by an ultrasound or by an electorhydraulic

probe.
„ The fragmented pieces are removed through the nephroscope.
What are the complications of PCNL?
„ Perforation of colon or pleura during placement of the needle.
„ Bleeding.
„ Perforation of the collecting system during insertion of the needle.
What is the indication for open surgery for renal stones?
If there is no facility for ECSWL or PCNL or if these modalities fail, open surgery is indicated for
removal of stones—nephrolithotomy or pyelolithotomy

CANNON BALL METASTASIS

Figrue 17.12: This is a plain X-ray of chest PA view showing normal bony cage. The diaphragm domes are
normal. There are multiple rounded opacities in both lung fields suggestive of cannon ball metastasis in
both lungs (Courtesy: Dr AG Ghosal, IPGME & R, Kolkata)

What do you mean by a PA view chest X-ray?

Patient faces the X-ray film and X-ray exposure is done from the back (Fig. 17.12). The X-ray is
done centering the T5 vertebra from a distance of 1.85 meter with 60–80 kV radiation.
In PA view the heart shadow and lung fields are seen better.
What do you mean by AP view of the chest X-ray?
The X-ray film is kept at the back and X-ray exposure is done from the front. Posterior chest
wall is seen better and the vertebrae intervertebral disc space is seen better.
What are the important things you look for in chest X-ray?
„ Bony cage—The ribs, vertebral body and the transverse processes, clavicle, the manubrium
sterni.
 Chapter 17 X-rays 693

„ The trachea.
„ The cardiac shadow and assessment of cardiothoracic ratio.
„ The diaphragm- the dome level—normally 6th rib anteriorly and 10th rib posteriorly, the
costophrenic angle.
„ The lung fields—the bronchovascular markings.
„ The hilar region.
„ Below diaphragm—Free gas under the domes of diphragm, dilated bowel loops, displacement
of fundal gas shadow, interposition of colon between liver and diaphragm (Chilaiditis
syndrome).
What are Kerley’s lines in Chest X-ray?
There are two type of Kerley’s line seen in chest X-rays:
Kerley’s A lines: These are 1–2 mm nonbranching lines radiating from the hilum, 2–6 cm long.
This is due to thickened interlobular septa.
Kerley’s B lines: These are transverse 1–2 mm nonbranching lines at lung bases perpendicular
to the pleura,1–3 cm long. This is also due to thickened interlobular septa.
What are the important causes of cannon ball shadows in chest X-ray?
This may be due to (Fig. 17.13):
„ Metastasis
„ Benign lesion
• Fungal infection—Histoplasmosis, coccidioodomycosis, aspergillosis.
• Parasitic infection—Filarial infection, hydatid disease.
• Sarcoidosis.
• Wegener’s granulomatosis.
• Rheumatoid nodules.

Figure 17.13: Similar X-ray as in Figure 17.12 showing cannon ball

metastasis in both the lung fields
 Chapter 17 X-rays 695

• Sputum cytology
• Bronchoscopic examination
• CT guided FNAC.
How will you treat pulmonary metastasis?
Pulmonary metastasis usually indicates advance disease and treatment is mainly palliative:
„ Treatment of the primary lesion.
„ For pulmonary lesion:
• Chemotherapy.
• Hormone therapy.
„ Surgery—Metastatectomy or segmental lung resection.

When will you consider surgical treatment for chest metastasis?

If there are multiple lung metastasis or bilateral metastasis, treatment is mainly palliative and
surgery is not very helpful. Surgical treatment is helpful when:
„ Primary tumor has been dealt with adequately and there is no evidence of local recurrence.
„ Solitary lung metastasis is most suitable. Multiple lung metastasis confined to one lobe may
also be considered for surgical resection.

SUBPHRENIC ABSCESS (FIG. 17.14)

Figure 17.14: This is a plain X-ray of chest PA view with upper part of abdomen
showing fluid collection in the right subphrenic region with a horizontal air fluid
level. There is a homogeneous opacity in the right lower zone of the lung field
suggestive of consolidation of the right lower lobe of the lung. This appearance
is suggestive of right sided subphrenic abscess with consolidation of right lower
lobe of lung (Courtesy: Dr PS Pal, BSMC, Bankura, West Bengal)

What are the subphrenic spaces?

The arrangement of the peritoneum results in formation of a number of spaces below the
diaphragm. These are called subphrenic spaces.
There are four intraperitoneal spaces and three extraperitoneal spaces.
There are three subphrenic spaces on either side and one approximately in the midline.
698 Section 4 X-rays

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)

(FIGS 17.16 TO 17.18)

Figure 17.16: This plate shows a series of pictures of endoscopic retrograde

cholangiopancreaticography. The endoscope is in situ. The normal pancreatic duct
is seen. The gallbladder is opacified and there are multiple filling defects in the
gallbladder. The common bile duct is visualized well, appears dilated and shows
a radiolucent filling defect in the lower end of the bile duct. In lower pictures,
a Dormia basket catheter is seen and the bile duct stone has been extracted
endoscopically (Courtesy: Dr GK Dhali, IPGME & R, Kolkata)

Figure 17.17: This plate shows a series of pictures of endoscopic retrograde

cholnagiography showing a dilated common bile duct and the hepatic duct with
a rounded filling defect in the bile duct suggestive of a radiolucent bile duct
stone. The cystic duct and the gallbladder is visualized well and there are multiple
small rounded fillng defects within the gallbladder suggestive of radiolucent gall-
stones. Dormia basket catheter is seen in lower two pictures and the bile duct
stone has been extracted endoscopically. The pancreatic duct is not seen in these
plates (Courtesy: Dr Kshaunish Das, IPGME & R, Kolkata)
 Chapter 17 X-rays 699

Figure 17.18: These are two pictures from ERCP series. In first picture endoscope
is seen in situ. The gallbladder is opacified well. The common bile duct, hepatic
duct and intrahepatic biliary radicles are grossly dilated. There is a radiolucent
filling defect in the bile duct suggestive radiolucent common bile duct stone.
This is a diagnostic ERCP procedure as no therapeutic intervention has been done
(Courtesy: Dr Jayanta Dasgupta, IPGME & R, Kolkata)

How an ERCP is done?

„ This is done in a gastroenterology unit with facility for X-ray and fluoroscopy.
„ A side viewing upper GI endoscope is used.
„ The procedure is done under sedation using midazolam or short intravenous anesthetic like
propofol.
„ Patient is placed in prone position with head turned to the right side.
„ A mouth guard is inserted in between the teeth, and the endoscope is inserted slowly.
„ The endoscope is inserted into the duodenum and the major papilla is localized on the
posteriomedial wall of the second part of the duodenum.
„ A cannula is inserted through the side channel of the endoscope and the cannula is inserted
into the ampulla and then electively into the pancreatic duct and the bile duct.
„ The contrast (urograffin 60%) is then injected through the cannula and pancreatogram and
the cholangiogram is obtained.
How do you know that the cannula has gone into the pancreatic duct or the bile
duct?
This can be ascertained by following the direction in which the cannula is going. If the cannula
goes obliquely across the vertebral body it is most likely to go into the pancreatic duct. If the
cannula has gone into the bile duct it will be seen going vertically up along the side of the
vertebral body.
How will ascertain the ductal diameter during ERCP?
The adult endoscope is 13 mm, so the duct is compared with the endoscope diameter and its
approximate dimension may be assessed.
700 Section 4 X-rays

How will you extract stone from bile duct endoscopically?

„ This is achieved by endoscopic sphincterotomy and stone removal by using a Dormia basket
catheter.
„ Patient's prothrombin time should be more than 80%.
„ Once ERCP is done and the stone is seen, the size of the stone is to be measured. Stones larger
than 1.5 cm cannot be removed endoscopically by endoscopic sphincterotomy.
„ An endoscopic sphincterotomy is done at 12’oclock position by using a endoscopic
papillotome and by passing diathermy current.
„ A guide wire is passed through the side channel of endoscopic beyond the stone.
„ A Dormia basket catheter is introduced through the side channel of the endoscope over the
guide wire into the bile duct in closed position beyond the stone. The Dormia basket is then
opened and the stone is lodged within the basket. The basket is withdrawn and the stone is
removed from the bile duct through the papilla. The stone can be left in the duodenum to be
extruded with stool or may be retrieved outside along with the endoscope.
What are the complications of ERCP?
ERCP may be associated with a number of complications:
„ Cholangitis
„ Acute pancreatitis
„ Bleeding
„ Duodenal injury.

Other questions related to bile duct stones (see Long Case on Choledocholithiasis.

WORM IN COMMON BILE DUCT (FIG. 17.19)

Figure 17.19: This is one of the skiagram from ERCP series showing dilated bile
duct and intrahepatic biliary radicles. There is a long linear filling defect in the bile
duct suggestive of a round worm in the bile duct (Courtesy: Dr Abhijit Chodhury,
IPGME & R, Kolkata)
702 Section 4 X-rays

ERCP—CHRONIC PANCREATITIS (FIGS 17.20 AND 17.21)

Figure 17.20: This is one of the skiagram from endoscopic retrograde

cholangiopancreaticography series showing normal bile duct. The
gallbladder is also opacified. No filling defect is seen. The pancreatic
duct is dilated, suggestive of chronic pancreatitis (Courtesy: Dr Sukanta
Roy, SDLD, IPGME & R, Kolkata)

Figure 17.21: This is a skiagram of ERCP showing dilated pancreatric

duct. The common bile duct is dilated and there is narrowing at the
terminal part of the common bile duct. The gallbladder is opacified
and there is a radiolucent filling defect in the lumen of the gallbladder.
So, this is suggestive of chronic pancreatitis with CBD compression
and cholelithiasis (Courtesy: Dr Sumit Sanyal, SDLD, IPGME & R, Kolkata)

How can you see these stones better?

Majority of the pancreatic stones are radiopaque, so are better seen in a plain X-ray of
abdomen.
 Chapter 17 X-rays 705

T-TUBE CHOLANGIOGRAM (FIGS 17.22 AND 17.23)

Figure 17.22: This is one of the skiagram from T-tube cholangiogram series. The
T-tube is seen in situ. The common bile duct, hepatic ducts and the intrahepatic
biliary radicles are dilated and there are two filling defects within the lumen of the
bile duct. These are suggestive of residual radiolucent common bile duct stones. The
dye has gone into the duodenum suggesting no obstruction in the terminal bile
duct (Courtesy: Dr Suprya Ghatak, SDLD, IPGME & R, Kolkata)

Figure 17.23: This is one of the skiagram from T-tube cholangiogram series
showing T-tube in situ. The bile duct is dilated and there is a radiolucent
filling defect at the lower end of the bile duct. The dye, however, has
reached the duodenum. This X-ray appearance is suggestive of residual
stone in the bile duct following choledocholithotomy
 Chapter 17 X-rays 707

„ The T-tube is removed and the T-tube tract is dilated under fluoroscopic control.
„ A Dormia basket catheter is introduced through the T-tube tract into the bile duct and the
stones may be removed.
„ Alternatively, a choledoscope may be passed through the matured T-tube tract and the stones
from the bile duct may be removed under vision.
What is the role of extracorporeal shock wave lithotripsy?
Retained or recurrent bile duct stone may be fragmented by using extracorporeal shock wave
lithotripsy. An endoscopic sphincterotomy may hasten expulsion of the fragmented stone.
What are the other options for management of residual bile duct stones?
If the above measures fail, the options are:
„ Laparoscopic choledocholithotomy.
„ Open choledocholithotomy.

If the retained stone is detected after the removal of T tube how will you manage ?
1. Endoscopic sphincterotomy and stone extraction by a Dormia basket catheter introduced
through the endoscope.
2. Extracorporeal shock wave lithotripsy—If the stone is large it may not be suitable for ECSWL.
50% patient needs adjunctive procedure like endoscopic extraction, biliary lavage and
stenting.
3. Percutaneous transhepatic route may be used to pass a cholangioscope to visualize the
bile duct stones and removal by using Dormia basket catheter introduced through the
cholangioscope.
4. Laparoscopic or open choledocholithotomy.

BARIUM SWALLOW X-RAY OF ESOPHAGUS—ACHALASIA CARDIA (FIG. 17.24)

Figure 17.24: This is one of the skiagram from barium swallow X-ray of the esophagus
showing a smooth pencil shaped narrowing at the lower end of the esophagus
with dilatation of the esophagus proximal to this narrowing. This appearance is
characteristic of achalasia cardia (Courtesy: Dr Swadapriya Basu, IPGME & R, Kolkata)
710 Section 4 X-rays

BARIUM SWALLOW—CARCINOMA OF ESOPHAGUS (FIGS 17.25 AND 17.26)

Figure 17.25: This is one of the skiagram from barium swallow X-ray of
esophagus showing an irregular filling at the midesophagus. There is dilatation
of the proximal esophagus proximal to the site of narrowing. This appearance is
suggestive of carcinoma of the midesophagus

Figure 17.26: This is one of the skiagram of barium swallow X-ray of esophagus and
stomach showing an irregular narrowing at the level of gastroesophageal junction.
This appearance is suggestive of carcinoma at the lower end of esophagus and
gastroesophageal junction

What are the usual presentation of patients with carcinoma esophagus?

„ Dysphagia initially to solids, later on to both solids and liquids
„ Regurgitation of food
„ Anorexia and weight loss
„ Cough
„ Pain indicates infiltration of tumor to the adjacent tissues
„ Hoarseness of voice may indicate recurrent laryngeal nerve palsy
„ Neck mass due to lymph node metastasis
„ Hematemesis and melena.
 Chapter 17 X-rays 713

What is the role of radiotherapy in esophageal carcinoma?

Radical radiotherapy is effective in carcinoma esophagus particularly squmaous cell carcinoma
and may be an alternative to surgery in patient unfit for surgery.
However, postoperative or preoperative adjuvant radiotherapy does not improve survival.
What is the role of chemotherapy in esophageal carcinoma?
Combination chemotherapy with cisplatin, mitomycin C and 5-fluorouracil and bleomycin may
offer worthwhile palliation in advanced disease.
How will you offer palliation for dysphagia in advanced carcinoma of esophagus?
Relief of dysphagia may be done by:
„ Endoscopic stenting by Celestin or Atkinson tube.
„ Use of self-expanding metallic stent.
„ Endoscopic laser treatment may be used to core a channel through the tumor.
„ Bipolar electrocautery and coagulation with tumor probes that uses heat to destroy the tumor

cells and causes circumferential recanalization.

„ Brachytherapy to deliver intralminal radiation.

BARIUM MEAL X-RAY—CHRONIC DUODENAL ULCER (FIG. 17.27)

Figure 17.27: This is one of the skiagram of barium meal X-ray of stomach
and duodenum. The stomach is seen normal. The duodenal cap is not well
formed and there is an ulcer crater at the region of the duodenal cap. This
appearance is suggestive of a deformed duodenal bulb due to chronic
duodenal ulcer (Courtesy: Dr Subhendu Majhi, IPGME & R, Kolkata)
714 Section 4 X-rays

BARIUM MEAL X-RAY—BENIGN GASTRIC ULCER (FIGS 17.28 AND 17.29)

Figure 17.28: This is one of the skiagram from double contrast barium
meal series of stomach and duodenum showing an ulcer crater in
the lesser curvature. Surrounding mucosal folds are seen converging
towards the ulcer base. Double contrast has given a better delineation
of mucosal pattern of stomach. So this is a case of chronic gastric ulcer
(Courtesy: Dr Soumya Mondal, IPGEM & R, Kolkata)

Figure 17.29: This is one of the skiagram from the barium meal X-ray
of stomach and duodenum series taken 30 minutes after ingestion
of barium. There is a large ulcer crater at the lesser curvature. The
duodenum is also visualized and appears normal. This appearance is
suggestive of a chronic gastric ulcer (Courtesy: Dr Kamal Singh Kanwar,
IPGME & R, Kolkata)

Why do you say this is a benign gastric ulcer?

This appearance is suggestive of a benign gastric ulcer. The radiological characteristics of benign
ulcer are:
„ Ulcers along the lesser curvatures are mostly benign.
„ The ulcer crater projects beyond the lumen of the stomach.
 Chapter 17 X-rays 715

„ The mucosal folds converge towards the base of the ulcer.

„ Benign ulcer is usually round or oval whereas a malignant ulcer is irregular
„ Sometimes, a pencil thin-line of lucency may be found crossing the base of the ulcer. This is
due to preserved gastric mucosa with undermining of underlying submucosa.
How a double contrast barium X-ray of stomach and duodenum is done?
Patient is given an injection of buscopan to delay the emptying of stomach. Patient is then given
an effervescent tablet composed of calcium carbonate and an antifoaming agent. When this
tablet is swallowed with water it releases carbon dioxide. Patient is then given 150–200 mL of
high density barium. The double contrast study gives a very good delineation of mucosal pattern.
What further investigations should be done before initiation of treatment?
An upper GI endoscopy and multiple biopsies from the ulcer is essential before initiation of
treatment to exclude malignancy.
What are the etiological factors for development of chronic gastric ulcer?
How patients with chronic gastric ulcer presents?
What are the complications of gastric ulcer?
What is the medical treatment for chronic gastric ulcer?
What are the indications of surgery in chronic gastric ulcer?
What are the options of surgical treatment for chronic gastric ulcer?
See Long Case—Chronic Peptic Ulcer, Page No. 113-118, Chapter 3 and Surgical Pathology—
Chronic Gastric Ulcer, Page No. 742-744, Chapter 18.

BARIUM MEAL X-RAY—CARCINOMA STOMACH (FIGS 17.30 AND 17.31)

Figure 17.30: This is one of the skiagram from the barium meal series of stomach and duodenum taken 1
hours after ingestion of the barium. The picture shows a large irregular filling defect in the pyloric region of
the stomach. There is shouldering of the contrast material along the greater curvature of the stomach. This
appearance is suggestive of a proliferative growth in the pyloric region of the stomach. However, I would
like to see other plates of the series to confirm that this filling defect is persistent (Courtesy: Dr Subhra
Ganguly, IPGME & R, Kolkata)
716 Section 4 X-rays

Figure 17.31: This is one of the skiagram from barium meal X-ray of stomach
duodenum and part of the small intestine showing an irregular filling defect along
the greater curvature in the pyloric antrum region there is shouldering of the dye
along the greater curvature. This appearance is suggestive of a proliferative mass in
the pyloric region of stomach (Courtesy: Dr Saurav Das, IPGME & R, Kolkata)

What are the radiological characteristics of carcinoma stomach?

„ Mass lesion in the stomach.
„ The margin of the mass may exhibit a shouldring and forms an acute angle with the gastric
wall.
„ The pyloric antral region may be severely narrowed.
What are the macroscopic types of gastric carcinoma?
The gross types of carcinoma stomach may be:
„ Proliferative
„ Ulcerative
„ Infiltrating.

What do you mean by early gastric carcinoma?

What do you mean by advanced gastric carcinoma?
How patients with gastric carcinoma usually presents?
How will you confirm your diagnosis?
What investigations will help in staging of carcinoma stomach.
What operation you will do in patient with a growth in the pyloric antrum region?
See Long Case—Carcinoma Stomach, Page No. 97-100, Chapter 3.
 Chapter 17 X-rays 717

BARIUM MEAL X-RAY—GASTRIC OUTLET OBSTRUCTION AND DUODENAL

OBSTRUCTION (FIGS 17.32 TO 17.34)

Figure 17.32: This is one of the skiagram from barium meal stomach series
taken 8 hours after ingestion of barium. The stomach is hugely distended
and there is a mosaic appearance due to admixture of barium with
retained food particles in the stomach. The duodenum is not visualized
yet. This appearance is suggestive of gastric outlet obstruction (Courtesy:
Dr Amitava Sarkar, IPGME & R, Kolkata)

Figure 17.33: This is one of the skiagram from barium meal X-ray of
stomach taken 8 hours after intake of contrast material. The stomach is
hugely distended and there is a mosaic appearance due to admixture of the
contrast with the retained food particles. The duodenum is not visualized.
This appearance is suggestive of gastric outlet obstruction
 Chapter 17 X-rays 719

What are the presenting symptom of chronic duodenal ileus?

„ Early satiety.
„ Nausea and bilious vomiting.
„ Postparandial abdominal discomfort and pain.
„ Symptoms are often relieved in left lateral decubitus or knee chest position.
How the diagnosis maybe confirmed?
„ CECT scan abdomen may show the site of duodenal compression.
„ Combined superior mesenteric angiography and barium study.
What is the optimal treatment?
„ In acute presentation treatment is usually conservative—improvement of nutrition if required
by total parenteral nutrition. Motility enhancing drugs—metoclopramide may help.
„ In chronic duodenal ileus—requires surgical treatment.
• Duodenojejunostomy will bypass the obstruction.

Figure 17.34: This is one of the skiagram from barium meal X-ray of
stomach duodenum and small gut. There is gross dilatation of the 1st,
2nd and 3rd part of the duodenum. The mucosal folds in the duodenum
appeared prominent. This is a classic appearance of chronic duodenal
ileus (Courtesy: Dr Thakur Thusu, IPGME & R, Kolkata)
720 Section 4 X-rays

BARIUM MEAL FOLLOW THROUGH—ILEOCECAL TUBERCULOSIS/JEJUNAL

STRICTURE (FIGS 17.35 AND 17.36)

Figure 17.35: This is one of the skiagram from the barium meal follow through
examination of small and large intestine series taken 8 hours after ingestion of
the barium. There is gross narrowing of the terminal ileum, the terminal ileum
proximal to the narrowing is markedly dilated. The ileocecal junction is drawn
higher up. The cecum is deformed with loss of normal distensibility and is also
drawn higher up. This appearance is suggestive of ileocecal tuberculosis with
stricture of terminal ileum (Courtesy: Dr AN Acharya, IPGME & R, Kolkata)

Figure 17.36: This is one of the skiagram from small bowel enema
(enteroclysis) series showing a long jejunal tube in situ. A hugely
distended loop of jejunum is seen with stenosis at the end of the dilated
segment. This appearance is suggestive of a jejunal stricture
724 Section 4 X-rays

BARIUM MEAL FOLLOW THROUGH—RECURRENT APPENDICITIS (FIG. 17.37)

Figure 17.37: This is one of the skiagram from barium meal follow
through series taken 5 hours after ingestion of barium, showing the
ileocecal region and right half of the colon. The appendix is viusualized
but it shows multiple filling defects in the lumen suggestive of fecoliths.
This appearance suggests a pathological appendix (Courtesy: Dr Shamita
Chattarjee, Culcutta Medical College, Kolkata)

How are the fecoliths formed?

Fecoliths are formed by inspissated fecal matter, calcium phosphate, bacteria and epithelial
debris. The incidental finding of fecoliths in appendix is an indication for prophylactic
appendicectomy.
What are the etiological factors for development of acute appendicitis?
„ Bacterial infection—There is usually a mixed growth of both aerobic and anaerobic organism.
„ Obstruction of the lumen of the appendix by a fecolith, foreign body or fibrous structure is an
important predisposing factor.
„ Familial predisposition.
What are the classical presentation of a patient with acute appendicitis?
„ Symtoms:
• Periumbilical colicky pain which later shifts to the right iliac fossa. Coughing or sudden
movement exacerbates the pain.
• Fever—Usually there is mild rise of temperature. In early stages there may be no fever. High
temperature (greater than 38.5°C) usually suggests other cause—mesenteric adenitis or
urinary tract infection.
• Nausea and vomiting.
 Chapter 17 X-rays 727

BARIUM ENEMA—CARCINOMA COLON (FIGS 17.38 AND 17.39)

Figure 17.38: This is one of the skiagram from double contrast barium enema
series showing normal haustration and filling of the sigmoid, descending and
transverse colon. There is abrupt narrowing at the right colic flexure and a fine
streak of barium is seen going down in the ascending colon. This appearance
is suggestive of a stenosing lesion in the right colic flexure region, which may
be due to carcinoma of right colic flexure (Courtesy: Dr Sushma Banerjee,
IPGME & R, Kolkata)

Figure 17.39: This is one of the skiagram from double contrast barium enema
series showin normal left colon. There is abrupt narrowing of the contrast
column at the right colic flexure with thin stream of the barium column going
down the ascending colon. This appearance is suggestive of a stenosing
lesion in the right colic flexure and the ascending colon, may be due to
carcinoma colon (Courtesy: Dr Rezaul Karim, IPGME & R, Kolkata)
732 Section 4 X-rays

INTRAVENOUS UROGRAPHY (IVU)—HYDRONEPHROSIS (FIG. 17.40)

Figure 17.40: This is one of the skiagram from intravenous urography

series taken 25 minutes after injection of dye. The left kidney outline
and pelvicalyceal system is seen normal. The right kidney outline is
enlarged. There is gross dilatation of the right renal pelvis. The calcyces
are dilated and clubbed. There is abrupt narrowing at the pelviureteric
junction. This appearance is suggestive of unilateral hydronephrosis
(Courtesy: Prof Sudip Ch Chakroborty, IPGME & R, Kolkata)

How will you prepare patient for intravenous urography study?

„ No fluid restriction is required.
„ Patient should avoid solid food 6 hours before the procedure.
„ Oral purgative and antiflatulent tablet—the night before the procedure.
What contrast agents are used for IVU?
These are iodine containing contrast agent:
„ Ionic contrast like sodium diatrizoate or meglumine iothalamate.
„ Non-ionic contrast like omnipaque
The dose required is 300 mg of iodine per kg of body weight. In well hydrated patient the,
dose may be increased to 600 mg Iodine per kg body weight.
How intravenous urography is done?
„ At first a control X-ray of the KUB region is done to exclude any radiopaque calculi or any
calcification in the KUB region.
„ About 50 mL of contrast agent 76% urograffin (sodium diatrizoate) is injected slowly
intravenously and then serial radiographs are taken:
• One minute film will give a nephrogram phase.
• Five minute film will show early filling of the pelvicalyceal system and the ureter may be
visualized and any filling in the lower ureter may be seen well. In the delayed film, the
lower ureter will be overlapped by the full bladder.
734 Section 4 X-rays

INTRAVENOUS UROGRAPHY—CARCINOMA KIDNEY (FIGS 17.41 AND 17.42)

Figure 17.41: This is one of the skiagram from intravenous urography series taken 10 minutes after injection
of dye. The right kidney outline and the pelvicalyceal system are seen normal. The left kidney outline is
enlarged. There is distortion of the left pelvicalyceal system. The pelvis is pushed up. There is splaying (spider
leg deformity) of the calyces. There is amputation of some of the calyces. This appearance is suggestive of
carcinoma of the kidney (Courtesy: Dr Rajkumar Singh Mahapatra, IPGME & R, Kolkata)

Figure 17.42: This is one of the skiagram from IVU series taken 10 minutes after injection of the contrast. The
right kidney and the renal pelvis are normal. The left kidney outline is enlarged. The left renal pelvis is pushed
up. There is splaying of the calyces (spider leg deformity) and also there are amputation of some calyces. This
appearance is suggestive of carcinoma kidney (Courtesy: Dr Abhiram Majhi, CNMC, Kolkata)

How patients with carcinoma kidney usually presents?

What further investigations are required for evaluation of a patient of carcinoma
kidney?
How will you treat a patient of carcinoma kidney?
See Long Case—Carcinoma Kidney, Page No. 194-197, Chapter 4
 Chapter 17 X-rays 735

X-RAY SKULL—SKULL BONE FRACTURE (FIGS 17.43 AND 17.44)

Figure 17.43: This is a plain X-ray of skull AP view including both

maxillae, mandible and the upper part of the neck, showing a
comminuted fracture involving the left parietal bone. One of the
fracture fragment is seen depressed inward. This appearance is
suggestive of comminuted depressed fracture of the left parietal
bone (Courtesy: Dr Kaushik Ghosh, BIN/IPGME & R, Kolkata)

Figure 17.44: This is a lateral view plain X-ray of the skull with part of maxilla
showing a comminuted fracture involving the left parietal bone is suggestive
of depressed skull fracture involving the left parietal bone (Courtesy: Dr Kaushik
Ghosh, BIN/IPGME & R, Kolkata)

How do you say whether fracture fragments are depressed or not?

In lateral view, it is not possible to comment whether the fracture fragments are depressed or not.
The depressed fracture is better demonstrated in a AP view X-ray of skull where the depressed
fragment of the skull is seen pushed inward.
 Chapter 17 X-rays 737

„ VII and VIII nerve palsy.

„ Battle’s sign—ecchymosis over the mastoid region.
How will you confirm that the watery discharge is CSF?
The fluid is analyzed for beta transferrin, presnce of which confirms that the fluid is CSF.
Extradural and subdural hematoma.
See Surgical Problems, Page No. 598-600, Chapter 16.

CHEST X-RAY—CHEST INJURY (FIG. 17.45)

Figure 17.45: This is a straight X-ray of chest PA view with right shoulder and
upper part of abdomen showing multiple rib fractures on the right side involving
2nd, 3rd, 4th, 5th and 6th rib at two points and the intervening fragment of the
ribs are pushed inwards. The right long field appears hypertranslucent. There
is homogeneous opacity in the right hemithorax with a horizontal fluid level
suggestive of hemopneumothorax. The margins of the collapsed right lung is seen.
There is fracture involving the right clavicle. There is also evidence of subcutaneous
emphysema. So, this X-ray appearance is suggestive of multiple rib fractures with flail
chest with traumatic hemopneumothorax and fracture clavicle with subcutaneous
emphysema (Courtesy: Dr Sandip Roy, AMRI, Kolkata)

How will you count ribs in chest X-ray?

The ribs are counted from the back starting with the first rib.
Where is the margin of the collapsed lung?
The collapased lung is seen as a dense shadow lateral to the heart shadow.
How will you manage a patient presenting with major chest trauma?
Before going into detail evaluation of injury, I will first take measures to:
„ Maintain his airway
„ Breathing