Imaging for Students This page intentionally left blank Imaging for Students THIRD EDITION David A. Lisle FRANZCR Consultant Radiologist at Holy Spirit Northside, Brisbane Private, and St Andrew’s War Memorial Hospitals, Brisbane; Visiting Radiologist at Redcliffe District Hospital, Redcliffe; Associate Professor of Medical Imaging at the University of Queensland Medical School, Brisbane, Australia Hodder Arnold A MEMBER OF THE HODDER HEADLINE GROUP First published in Great Britain in 1995 by Arnold Second edition 2001 This third edition published in 2007 by Hodder Arnold, an imprint of Hodder Education and a member of the Hodder Headline Group, 338 Euston Road, London NW1 3BH http://www.hoddereducation.com Distributed in the United States of America by Oxford University Press Inc., 198 Madison Avenue, New York, NY10016 Oxford is a registered trademark of Oxford University Press © 2007 David A. Lisle All rights reserved. Apart from any use permitted under UK copyright law, this publication may only be reproduced, stored or transmitted, in any form, or by any means with prior permission in writing of the publishers or in the case of reprographic pro- duction in accordance with the terms of licences issued by the Copyright Licensing Agency. In the United Kingdom such licences are issued by the Copyright Licensing Agency: Saffron House, 6–10 Kirby Street, London EC1N 8TS Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the author nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. In particu- lar (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed. Furthermore, dosage schedules are constantly being revised and new side-effects recognized. For these reasons the reader is strongly urged to consult the drug companies’ printed instructions before administer- ing any of the drugs recommended in this book. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN-10 0 340 92591 4 ISBN-13 978 0 340 92591 1 1 2 3 4 5 6 7 8 9 10 Commissioning Editor: Sara Purdy Project Editor: Jane Tod Production Controller: Lindsay Smith Cover Designer: Laura DeGrasse Indexer: June Morrison Typeset in Goudy 10/14 pts by Charon Tec Ltd (A Macmillan Company), Chennai, India www.charontec.com Printed and bound in India by Replika Press Pvt Ltd What do you think about this book? Or any other Hodder Arnold title? Please visit our website at www.hoddereducation.com To my wife Lyn and our daughters Victoria, Charlotte and Margot This page intentionally left blank Contents Preface ix Pulmonary embolism 81 Acknowledgements xi Deep venous thrombosis 84 Venous insufficiency 84 1 Introduction to medical imaging 1 Hypertension 85 X-ray imaging 1 Interventional radiology of the peripheral Contrast materials 4 vascular system 86 Computed tomography 6 Ultrasound 10 6 How to read an abdomen X-ray 92 Scintigraphy (nuclear medicine) 14 The standard abdominal series 92 Magnetic resonance imaging 18 Method of assessment 92 Some specific findings on abdomen X-ray 93 2 Hazards and precautions in medical 26 7 Gastrointestinal system 103 imaging Imaging investigation of the Contrast media reactions 26 gastrointestinal tract 103 Radiation hazards 27 Dysphagia 106 Magnetic resonance imaging safety issues 29 Acute abdomen 107 Inflammatory bowel disease 112 3 How to read a chest X-ray 31 Gastrointestinal bleeding 113 Projections performed 31 Carcinoma of the stomach 115 Radiographic anatomy 32 Small bowel neoplasms 115 Assessment of the heart 35 Colorectal carcinoma 115 Pulmonary vascular patterns 37 Abdominal trauma 117 Mediastinal masses 38 Hilar disorders 40 8 Liver 120 Solitary pulmonary nodule 40 Characterization of liver masses 120 Multiple pulmonary nodules 41 Imaging investigation of jaundice 123 Diffuse pulmonary shadowing 42 Summary of interventional procedures Lobar pulmonary consolidation 48 of the liver and biliary tree 126 Pulmonary collapse 50 Pleural disorders 52 9 Urinary tract and male reproductive 129 system 4 Respiratory system 59 Imaging investigation of the urinary tract 129 Imaging investigation of the respiratory Investigation of a renal mass 130 system 59 Painless haematuria 133 Common pulmonary disorders 62 Renal colic and acute flank pain 135 Adrenal imaging 135 5 Cardiovascular system 71 Trauma to bladder and urethra 138 Imaging investigation of cardiac disease 71 Imaging in prostatism 138 Congestive heart failure 73 Adenocarcinoma of the prostate 139 Ischaemic heart disease 75 Investigation of a scrotal mass 141 Aortic dissection 77 Acute scrotum 142 Abdominal aortic aneurysm 79 Interventional radiology of the Peripheral vascular disease 80 urinary tract 143 viii Contents 10 Female reproductive system 145 Stroke 220 Ultrasound in obstetrics 145 Headache 226 Ultrasound in gynaecology 148 Other common indications for imaging Staging of gynaecological malignancies 151 in the central nervous system 228 Breast imaging 152 15 Head and neck 231 11 Skeletal trauma 157 Facial trauma 231 Radiographic anatomy of bone 157 Imaging of the orbit 232 Fractures and dislocations: general Imaging of the paranasal sinuses 234 principles 158 Imaging of the temporal bone 235 Fractures and dislocations: specific areas 167 Investigation of a neck mass 236 Investigation of a salivary gland calculus 238 12 Musculoskeletal system 181 Staging of carcinoma of the larynx 239 Imaging investigation of the Thyroid imaging 240 musculoskeletal system 181 Primary hyperparathyroidism 241 Internal joint derangement: methods of investigation 182 16 Paediatrics 243 Approach to arthropathies 185 Neonatal respiratory distress: the Some common bone conditions 188 neonatal chest 243 An approach to primary bone tumours 192 Patterns of pulmonary infection in children 246 13 Spine 196 Urinary tract infection 248 Radiographic anatomy 196 Hydronephrosis 252 Spine trauma 197 Investigation of an abdominal mass 253 Neck pain 205 Intussusception 257 Low back pain 206 Hypertrophic pyloric stenosis 257 Specific back pain syndromes: imaging Oesophageal atresia and tracheo- findings 207 oesophageal fistula 258 Sciatica 211 Gut obstruction and/or bile-stained vomiting in the neonate 260 14 Central nervous system 215 Non-accidental injury 263 Imaging investigation of brain disorders 215 Hip problems in children 265 Head trauma 215 Subarachnoid haemorrhage 218 Index 269 Preface Despite over 30 years of rapid technological develop- where a clinical problem demands assessment with CT ment and growing clinical demand, the specialty of or magnetic resonance imaging (MRI), there is often no Radiology or Medical Imaging continues to receive point ordering less sophisticated tests first. In the current scant attention in most medical curricula. The aims of climate of overstretched health budgets, the appropriate this, the third edition of Imaging for Students, remain the use of medical imaging is more important than ever. same as for the previous two editions. The first of these A major, and often forgotten consequence of mod- aims is the ability to interpret radiographs, or X-rays, in ern medical imaging is the incidental finding. Modern order to diagnose common conditions such as pneumo- ultrasound, CT and MRI scanners are highly sensitive nia, cardiac failure, intestinal obstruction and perfora- and incidental findings are common. A major radi- tion, fractures and dislocations. Second, I hope to ology journal recently devoted an entire issue to ‘inci- impart some understanding of how the various imaging dentalomas’. In my opinion, a patient who has been modalities work, including associated hazards. It is also put through one or more extra examinations to investi- important for students to have some idea about more gate a harmless incidental finding found on a test that invasive tests and procedures and how these may was not justified in the first place has been done a great impact on the patient. disservice by the medical profession. Radiologists may, Finally, it is more vital than ever for students to of course, refuse to perform tests that seem unwar- understand the appropriate ordering of more sophisti- ranted. This is not as easy as it may seem, as the radiol- cated and costly imaging examinations. The pace of ogist is not always privy to all of the pertinent technological advance in medical imaging has far out- information about an individual patient. In practical paced the ability of clinical research to keep up and day-to-day medical practice it is the responsibility of there is a trend for technologies to be introduced into the referring doctor to ensure that the potential bene- clinical practice before clinical efficacy or cost effec- fits of an imaging investigation outweigh its risks. tiveness has been established. These trends are trou- With these considerations in mind several changes bling for a number of reasons. First among these is the and updates have been added to the new edition. increasing level of radiation exposure, largely due to Chapter 1 is an introduction to the various imaging the more frequent use of computed tomography (CT) modalities. The bare essentials are provided here, with for common clinical problems. an ear for the kinds of questions students often ask me, The economic costs of modern medical imaging are questions such as ‘What do the terms T1 and T2 mean?’ expanding at a disconcerting rate. Despite the wide- and ‘Why is MRI so noisy?’. Chapter 2 gives an overview spread availability of expensive technologies, the history of common hazards of medical imaging, including the and clinical examination are still the foundation stones increasingly important issue of radiation exposure. The of medical practice. More often than not a correct diag- titles of Chapters 3 and 6 are self-explanatory: ‘How to nosis may be achieved with history and examination read a chest X-ray’ and ‘How to read an abdomen X-ray’.