1. X- Ray Review
By: Dr Wedad Bardisi

3. Atelectasis Right Lung
 Homogenous density right hemithorax
 Mediastinal shift to right
 Right heart and diaphragmatic
silhouette are not identifiable

5.  Atelectasis Right Lung
 Open Bronchus Sign
 Homogenous density right hemithorax
 Mediastinal shift to right
 Right heart and diaphragmatic silhouette
are not identifiable


7. Atelectasis Left Lung
 Homogenous density left hemithorax
 Mediastinal shift to the left
 Diaphragmatic and heart silhouette
are not identifiable

9.  Atelectasis Left Lower Lobe
 Inhomogeneous cardiac density
 Triangular retrocardiac density
 Left hilum pulled down


11.  Atelectasis Right Upper Lobe
 Density in the right upper lung field
 Transverse fissure pulled up
 Right hilum pulled up
 Smaller right lung
 Smaller right hemithorax


13. Cancer Breast
 Inflammatory Carcinoma
 Post-Radiation
 Larger right breast
 Inverted nipple
 Radiation Fibrosis of Lung
 Right lung smaller
 Right hemithorax smaller
 Paramediastinal fibrosis


15. Cystic Fibrosis - Bronchiectasis
 Bilateral diffuse
 Multiple cavities / Bronchiectasis
 Peribronchial fibrosis
 Prominent hilum
 Hyperinflated

17. Silicosis
 Egg shell calcification of lymph nodes
 Other findings include:
 Diaphragmatic pleural calcification
 Multiple cavities with fluid levels


19. Histoplasmosis
 Calcified nodes
 Calcified nodules in lungs


21. Visceral pleural calcification
 Open drainage with air fluid levels in
pleural space

23. Silicosis
 Diaphragmatic pleural calcification
 Other findings include:
 Multiple cavities with fluid levels
 Egg shell calcification of lymph nodes

25. Squamous Cell Carcinoma Lung
 Cavity
 LUL mass
 Thick walled cavity
 Eccentric location of cavity
 Fluid level

27. Lung Cancer / Squamous Cell
 Mass density
 Anterior segment of LUL
 Thick wall cavitation

29.  Rib Fracture / Hematoma

31. Consolidation / Lingula
 Density in left lower lung field
 Loss of left heart silhouette
 Diaphragmatic silhouette intact
 No shift of mediastinum
 Blunting of costophrenic angle


33. Consolidation / Left Lower Lobe
 Density in left lower lung field
 Left heart silhouette intact
 Loss of diaphragmatic silhouette
 No shift of mediastinum
 Blunting of costophrenic angle


35. Lobar Pneumonia Right Middle Lobe
 Vague density right lower lung field
 Indistinct right cardiac silhouette
 Intact diaphragmatic silhouette
 Lateral Density corresponding to RML
 No loss of lung volume
 No air bronchogram

37. Consolidation Right Middle Lobe
 Density in right middle lung field
 Loss of right cardiac silhouette
 Pulmonary artery overlay sign
 Air bronchogram not visible
 Minor movement of fissure


39. Consolidation Left Lower Lobe
 Density in left lower lung field
 Left heart silhouette intact
 Loss of diaphragmatic silhouette
 No shift of mediastinum
 Pneumatocele

41. Pneumoperitoneum

 Air under diaphragm

43.  Diaphragmatic paralysis

45.  Lung Metastasis/Alveolar Form
Cancer Pancreas
 Soft fluffy lesions
 Air bronchogram
 Coalesing lesions


47. Pulmonary Edema
Acute Diffuse Alveolar
 Bilateral
 Diffuse
 Butterfly pattern
 Soft fluffy lesions
 Coalescing
 Air bronchogram

49. Emphysema
 Hyperlucent lung fields
 Multiple blebs
 Avascular zones
 Prominent pulmonary arteries
 Radiologic TLC

51. Milary Tuberculosis
 Interstitial nodules
– Uniform size
– Sharper edges

53. Lymphangitic Metastasis
 Cancer Breast
 Kerley lines
 Subpulmonic effusion on right

55. Tuberculosis Spine
 Loss of intervertebral space
 Vertebral collapse
 Cold abscess is not present
 PA view is not diagnostic.

57.  Mediastinal Lymph Nodes
 Extrapleural
 Polycyclic margin
 Anterior mediastinum

59.  Air Fluid Level
 Inhomogeneous cardiac density
 Retrocardiac density
 In mediastinum in PA view
 Hiatal hernia
 Other findings include:
 Pleural fibrosis on right

61.  Sarcoidosis / Miliary Nodules / Hilar
Nodes

62. Mass density
 Mass density can be encountered in lung cancer,
benign tumors, sarcoma, lymphoma, Wegener's
and blastomycosis and tuberculoma.
 Radiological criteria for a mass lesion are chest
lateral and PA views.
 Density
 Round or oval
 Sharp margins
 Homogenous density (exception: air
bronchogram in lymphoma and blastomycosis)

63.  No respect for anatomy (in cancer)
 Can break down leading to thick walled cavity
 May show calcification (histoplasmoma,
tuberculoma, hamartoma)
 Note in a gross cut section a mass which is well
demarcated from the adjacent normal lung.
Malignant tumors have infiltrating edges, while
benign tumors are rounded and well circumscribed.

65.  Mass
 Round or oval
 Sharp margin
 Homogenous
 No respect for anatomy
 Lung Cancer: Large cell


67.  Round homogenous density
 Sharp margins
 Medial portion pleural based (acute
angle)
 This is a case of squamous cell lung
cancer.

69. Hilar Nodes
 bilateral symmetrical hilar nodes and
para tracheal nodes.
 A clear space between the nodes and
heart, identifies the nodes as hilar.


71. Sarcoidosis
 Alveolar Form
 Symmetrical hilar nodes
 Mediastinal nodes
 Multiple bilateral mass densities with
alveolar features
 Soft coalescing

73.  Lung Cancer
 RUL primary lesion
 Para tracheal nodes

74. Pleural Effusion
 Fluid accumulates in the pleural space.
 Irrespective of the nature of fluid, radiologically they will look
similar.
 Radiological criteria are: Density
 In dependent portion
– Costophrenic angle in PA view
– Anterior and posterior portions of gutter in lateral view
– Along sides in lateral decubitus position
– Along posteriorly in supine position, giving diffuse haziness on
the side of effusion
 Silhouette of upper limit of density
– Upper margin high in axilla in PA view
– Upper margin high interiorly and posteriorly in lateral view
 Blunting of costophrenic angle
 Lack of identifiable diaphragm (silhouette sign principle).

75.  Massive
 Unilateral VS bilateral
 Sub pulmonic
 Loculated
 Supine position
 Lateral decubitus position

77.  Pleural Effusion
 Homogenous density
 Meniscus maximum in axilla
 Loss of cardiophrenic angle
 Loss of diaphragmatic and right
cardiac silhouette


79.  Loculated Pleural Effusion
 Empyema
 Haziness of right hemithorax
 Density not corresponding to lobar anatomy
 Diaphragmatic and cardiac silhouettes intact
 Lateral film below
– Loculated fluid overlying vertebral column

81.  Pleural Fibrosis
 Small right hemithorax
 Diffuse haziness
 Tracheal shift to right
 Blunted costophrenic angle
 Lines not corresponding to fissures


83.  Consolidation Right Upper Lobe /
 Air Bronchogram
 Density in right upper lung field
 Lobar density
 Loss of ascending aorta silhouette
 No shift of mediastinum
 Transverse fissure not significantly
shifted
 Air bronchogram

85.  Pneumothorax
 Atelectatic lung is dense implying that
it is abnormal ("normal lung" will not
be dense)
 Bleb is easily recognized in the close-up
below


87.  Heart Failure/Rapid Resolution
 Such rapid resolution as seen above is
usually due to secondary cause such
as fluid overload.

89.  Subcutaneous Emphysema
 Diffuse interstitial fibrosis

91. Ankylosing Spondylitis
 Spine film: Bamboo spine
 Cervical spine
 Bilateral non-specific upper lobe
disease
 .

93.  Aneurysm Arch of Aorta
 Mediastinal mass
 Extrapleural


94. Bronchiectasis
 Radiologic findings include:
 Normal appearing CXR in most
 Tubular shadows
 Tram line
 Gloved fingers
 Mucocele
 Ring shadows with thickened bronchial walls
 Air fluid levels
 Watch for dextrocardia
– Immotile cilia syndrome
 Diffuse lung fibrosis
– Due to recurrent infections

96. Cystic Fibrosis - Bronchiectasis
 Bilateral diffuse
 Multiple cavities / Bronchiectasis
 Peribronchial fibrosis
 Prominent hilum
 Hyperinflated


98.  Bronchiectasis
 Multiple bilateral basal air fluid levels

100.  Pleural Effusion
 Rheumatoid Arthritis
 Chest lateral and hand x-rays.


102.  Diagnosis
 Acute colonic pseudo-obstruction or
Ogilvie syndrome
 Differential
 Mechanical colonic obstruction
 Toxic megacolon
 Mesenteric ischaemia

104. Case
 This 19 year old male presented with a
history of 3 stone weight loss (42 lbs to
our US cousins, 19kg to the metric world)
over a period of three months. He
complained of malaise and was anaemic.
Endoscopy of the upper gastrointestinal
tract was normal.
 A barium small bowel meal was
performed.

105.  Findings
 Changes of early/intermediate Crohn's
disease, with thickened folds, tending to
asymmetry and obliteration in places. There
are small apthous ulcers, and nodules, with
normal diameter bowel. There is a linear
mesenteric ulcer (arrowed, lower image
 Small bowel Crohn's disease

107.  Avascular necrosis of the femoral head
 differential for the causes:
 Toxic
Steroids, Anti-inflammatory drugs, Alcohol,
Immunosuppressives, Traumatic, Idiopathic,
Fractures (femoral neck, talus, scaphoid),
Radiotherapy, Heat (burns), Fat embolism

108.  Inflammatory
Rheumatoid arthritis, SLE,
Scleroderma, Infection - eg. pyogenic
arthritis, Pancreatitis

 Metabolic and endocrine
Pregnancy, Diabetes, Cushing's
syndrome, Hyperlipidaemias, Gout

109.  Haemopoetic disorders
Haemoglobinopathies, Polycythaemia
rubra vera, Haemophilia
 Thrombotic and embolic
Dysbaric osteonecrosis (divers),
Arteritis

111.  Posterior dislocation of the shoulder
 A painful shoulder after a fall
 This patient complained of pain and
restricted movement in the shoulder,
having blacked out and fallen over. What
abnormality is demonstrated? What other
view would be useful? And if the patient
was unable to abduct the arm, what
other view can be performed?

112.  Findings
 Posterior dislocation is much less common
than anterior dislocation (approximately 4%
of dislocations), and is frequently much less
obvious on the AP view alone, requiring a
further view for confirmation. This may be
either an axial view of the shoulder, or a
tangential view of the scapula if the patient
can not raise their arm sufficiently for the
former.

113.  An elderly patient with change in bowel habit and
dysuria
 This patient presented with a history of change of
bowel habit and lower abdominal pain. There had
been a brief episode of rectal bleeding a few weeks
earlier, and some dysuria.
 The General Practitioner had recently prescribed a
course of antibiotics for a suspected urinary tract
infecton, but this had not helped.
 A barium enema was arranged to investigate the
rectal bleeding

115.  Diagnosis:
 Moderately differentiated
adenoarcinoma of the colon with
colovesical fistula

117.  Paget's disease of the humerus &
pathological fracture

119.  Anterior mediastinal Seminoma Young
adult man with chest discomfort and
left shoulder pain

121.  Bone mets and R. pleural effusion

123.  Left upper lobe atelectasis

125.  Haemothorax
 T tube

127.  Cardiomegaly bilateral

129.  Pulmonary artery enlargement

131.  Atlantoaxial instability (cervical
rheumatoid arthritis). Flexion and
Extension views show the distance
between the atlas and the dens
anteriorly in the extension view is 2.3
mm while in the flexion view the
distance is 7.5 mm.

133.  Adult woman with chronic left wrist
pain. Avascular necrosis of the
scaphoid bone. Age indeterminate
scaphoid wrist fracture. Proximal
scaphoid bone is sclerotic due to
osteonecrosis.

135.  Gout : Marginal erosions with
overhanging edges and sclerotic
borders at numerous joints throughout
the hands and feet. Interphalangeal
joint space narrowing. Soft tissue
swelling with associated soft tissue
calcifications

137.  Bone metastases to the finger.
Radiograph shows a destructive
expanded osteolytic lesion in the
metacarpal of the thumb in a 55-year-old
man with lung carcinoma.

139.  Advanced RA. Radiograph of the hand
shows severe destruction and
mutilation of the radiocarpal,
intercarpal, carpometacarpal, and
metacarpophalangeal joints.
Intercarpal ankylosis is noted.
 There is also subluxation and deviation
of the fourth and fifth fingers

141.  Skeletal sickle cell anemia. H
vertebrae. Lateral view of the spine
shows angular depression of the
central portion of each upper and
lower endplate.

143.  Ankylosing Spondylitis 35-year-old
male presents with low back pain of
many months duration that is not
relieved by rest. In addition, significant
neck stiffness.

144.  Findings: AP and lateral view of the
lumbosacral spine demonstrate flowing
osteophytes with bony bridges
between the margins of adjacent
vertebral bodies seen laterally at all
the visualized levels.

145.  In addition on the lateral view there is
anterior syndesmophyte formation
with straightening of the normal
curvature of the lumbar spine.
Vertebral body height is maintained
and there is squaring of the anterior
vertebral margins. In addition,
ankylosis of the posterior diarthrodial
joints. The sacroiliac joints are fused
bilaterally

147.  Lateral radiograph shows sclerotic
metastasis of the L2 vertebra in a 54-
year-old man with prostatic carcinoma

149.  Osteomalcia malabsorption

151.  Skeletal sickle cell anemia.
Osteonecrosis

153.  Seventy-year-old with dysphagia
Esophageal diverticula (probably pulsion
variety), hiatal hernia, GE reflux Two wide-necked
diverticula at the junction of the mid
and distal esophagus that retain contrast
after the esophagus empties. There were
tertiary, nonpropulsive contractions, a large
sliding hiatal hernia, and GE reflux to the
thoracic inlet.

159.  Young man with hematuria IVP
shows a dual renal pelvis on the left
with partial duplication of the left
ureter. Ultrasound shows a cortical
bar, compatible with duplication of the
collecting system.Diagnosis: Partial
duplex, left kidney

161.  LLL col

163.  Massive
 Massive Pleural Effusion

165.  Atelectasis Right Lung

167.  Left upper lobe collapse due to left
hilar mass