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Rational Imaging Investigation for Common Diseases

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Rational Imaging Investigation for Common Diseases Rational Imaging Investigation For Common Diseases MITRA KHALILI MD BASIC CONCEPTS IN DIAGNOSTIC IMAGING Modalities Available in Radiology Plain Film / X-Ray/Mammography Fluoroscopy Ultrasound CT MRI Nuclear Medicine/Molecular Imaging Angiography/Interventional X-Rays Most widely performed imaging exam X Rays are emitted and detected in cassette Cassette can generate either a film or a digital image Films are kept ‘on file’ or in a digital archive Most Useful Applications for Plain X-Rays Chest Musculoskeletal Abdomen: limited usefulness Fluoroscopy Utilizes X-Rays Real-time imaging Utilizes image intensifier Involves use of contrast agents Main Uses of Fluoroscopy Gastrointestinal Imaging Genitourinary Imaging Angiography Other Intraoperative Foreign body removal Musculoskeletal Gastrointestional Fluoroscopy Barium Swallow Upper GI Small Bowel Series Enteroclysis Contrast Enema Defecography Single Contrast vs Double Contrast Single Contrast Generally uses just thin Barium Distends lumen with high density material Easier for patient/less mucosal detail Double Contrast/Air Contrast Thick barium coats lumen Effervescent tablets ingested to distend lumen with air Produces ‘see-through’ images with greater mucosal detail Greater sensitivity for small lesions, polyps, ulcers Genitourinary Fluoroscopy Cystogram Voiding cystourethrogram Retrograde urethrogram Hysterosalpingogram Cystogram Usually in adult patients Looking for tear or intraluminal mass Catheter placed and bladder filled with contrast to capacity: usually 300-500 ml. Spot films obtained when full Post void film: usually overhead Voiding Cystourethrogram VCUG Usually in children with history of UTI Searching for vesicoureteral reflux In males, evaluate for urethral abnormalities: posterior urethral valves Same as cystogram except when full patient voids under fluoro with spot films Retrograde Urethrogram RUG Male patients Pelvic Trauma Post-infectious: STD- looking for stricture Different techniques Meatus occluded and contrast injected into urethra under fluoro Hysterosalpingogram Used to evaluate endometrial canal and fallopian tubes Infertility and uterine anomalies Dye injected into cervical os under fluoro Injection continued with goal to opacify the fallopian tubes and spill contrast into peritoneum Computed Tomography (CT • Cross Sectional imaging modality • Mobile X-ray tube that rotates around a patient Slices of X-ray transmission data reconstructed to generate image • Data displayed in multiple window settings (lungs parenchyma, bone, etc.) • Density measurements/Hounsfield Units analyze chemical component of tissue HU: -150-0 = fat, 0 = water, 0-20 = serous fluid, 45-75 = blood, 100-1000 = bone/calcium CT Contrast Agents • Intravenous contrast: Differentiate blood vessels vs. vascular internal organs • Enteric contrast: Differentiate bowel vs. intra- abdomina fluid/masses • Rectal contrast • Retrograde urinary bladder contrast CT Applications • Neuro-imaging -Acute head trauma, acute intracranial hemorrhage -Low sensitivity for early ischemic stroke, intracranial metastatic disease, white matter degenerative disease • Head and Neck imaging -Soft tissue of neck, paranasal sinuses, temporal bone imaging, orbital wall imaging CT Applications • Body Imaging -Chest, Abdomen, Pelvis (with enteric and IV contrast) -Pulmonary nodules, Renal Calculi (without contrast) -Acute appendicitis (with enteric and IV contrast) -Specialized protocols: Liver masses, pancreatic tissue, renal masses, adrenal masses CT Applications • Acute Abdomen -decrease rate of false laparotomy procedures • Trauma Spine Imaging (cervical, thoracic, lumbar) • Other osseous structures (pelvis, extremities) • Vascular Imaging -CT angiography--- i.e. coronary arteries Magnetic Resonance Imaging (MRI) • Multi-planar scanning without ionizing radiation • Images generated using powerful magnets and pulsed radio waves passing through the body • Data from Pt’s body used to generate image • Field strength of magnets 0.3-3.0 Tesla MR Applications • Neuro-imaging -Excellent tool due to high soft tissue contrast resolution -Abundant water content of CNS allows for imaging soft intracranial tissue • Head and Neck imaging -Multi-planar capability allows for monitoring extent of disease -Differentiating subtle soft tissue boundaries of head and neck MR Applications • Body Imaging -Thorax: mediastinal, hilar, chest wall abnormalities -Limited lung imaging due to artifacts • New advances in breast imaging • Potentials for cardiac MRI with coronary MR angiography MR Applications • MSK Imaging - High sensitivity for neoplastic, inflammatory, and traumatic conditions of bone and soft tissue - T1-weighted---fluid collections and abnormalities in fatty marrow - T2-weighted---lesions in both marrow and soft tissue Respiratory system Routine admission and preoperative CXR: - Admission chest radiographs were recommended only on patients with clinical findings of cardiopulmonary disease or elderly patients unable to provide an accurate history or undergo a reliable physical examination. - preoperative chest radiograph : advanced patient age (especially >70 years) and certain other patient- and procedure-related risk factors (eg, history of cardiopulmonary disease, unreliable history and physical examination, high-risk surgery) . - Decision should derive to investigate a clinical suspicion for acute or unstable chronic cardiopulmonary disease that could influence patient care. Portable CXR in ICU - Daily in acute cardiopulmonary problems - CXR after specific procedure - CXR for presence or course of disease Respiratory system Acute respiratory illness in immunocompetent patient: - >40 y/o - Dementia - Hemoptysis - Positive physical exam - Associated abnormality ( WBC, hypoxemia) - CHF, coronary artery disease, drug induced acute respiratory disease Respiratory system CXR in COPD: - Complications such as pneumonia or pneumothorax, CHF, coronary artery disease ,chest pain, leukocytosis,edema Respiratory system CT in ARI: - severe pneumonia -Febrile neutropenic patient with normal CXR - Clinical suspicious for SARS or H1N1 and normal CXR Respiratory system ARI in immunocompromised patient: - CXR - CT Respiratory system Dyspnea: -CXR : Chronic, severe,>40 y/o,cardiovascular or pulmonary or neoplastic disease - HRCT: When CXR is non revealing or it reveal abnormality but no definitive diagnosis Respiratory system Hemoptysis : Common causes include chronic bronchitis, bronchiectasis, pneumonia, fungal infections, tuberculosis, and malignancy and rarely vasculitis. - CXR - CT : suspicious chest radiograph findings or risk factors (>40 years of age, >30 pack-year smoking history). - MDCT angiography : If hemoptysis recurs Massive hemoptysis : Contrast-enhanced MDCT prior to embolization or surgery can define the source of hemoptysis as bronchial systemic, nonbronchial systemic, and/or pulmonary arterial. Respiratory system Screening for pulmonary metastasis: - CXR: baseline - CT: Bone and soft tissue sarcoma, melanoma and head and neck carcinoma, RCC and testicular carcinoma with elsewhere metastatic disease Respiratory system Rib fracture: - CXR (PA view):indicated - X-Ray rib view: usually not appropriate - CT: usually not appropriate GI system Acute abdominal pain and fever Abdominal abscess in postoperative or nonoperative state: - CT with contrast Acute abdomial pain: 1. Perforation/Obstruction - AXR and CXR - CT: High clinical suspicious with negative X-Ray - Ba study should not be used as a primary modality in diagnosis of small bowel obstruction. GI system 2. Appendicitis : -CT with oral and IV contrast : most accurate imaging - US : in children - MRI : in pregnancy with equivocal US exam 3. Pancreatitis : - US : gallstone evaluation - CT with iv contrast : choice - MRI with iv contrast and MRCP 4. cholecystitis: - US GI system Dysphagia: - Barium swallow : Motility disorders and subtle stricture in comparison with endoscopy Esophageal perforation : - CXR - Contrast swallow - CT : sensitive for detection of perforation Dyspepsia : - Endoscopy : If negative or symptoms persist or alarm signs are present Barium meal GI system Jaundice : 1. Obstruction/ non obstruction 2. Benign/ malignant 3. Operative/ non operative Stone : US / MRCP Malignancy : Cross-sectional imaging ( CT / MRI ) GI system Palpable abdominal mass : - US and CT : First line procedure GU system Acute onset flank pain (stone?) : most complain - CT without contrast : choice method - IVP - US and AXR : Children, pregnancy Acute scrotal pain : - Strong clinical suspicious to torsion : Explore - Suspicious : Doppler ultrasound - RNSI : Long examination time and less availability GU system Hematuria : - Gross hematuria clearly conveys a much higher risk of malignancy than microscopic disease and should be thoroughly evaluated. - Young women with a clinical picture of simple cystitis and whose hematuria completely and permanently resolves after successful therapy will probably not require any imaging as well as glomerulopathy. - Risk factors such as cigarette smoking, occupational exposure to chemicals, irritative voiding symptoms, a full urologic evaluation for urothelial carcinoma is recommended if even one urinalysis documents microhematuria. GU system CTU : CTU is the first study in patients with hematuria . Cystoscopy : The imaging evaluation will almost always be accompanied by cystoscopy to evaluate the urinary bladder US : In patients who have contraindications
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