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INTRODUCTION TO RADIOLOGY Casey Sams, MD Introduction to Radiology I: Radiology Who we are What we do Our tools How can you help us help you II: Contrast III: Plain Film Imaging of the Abdomen IV: Radiology at UNC V: Parting Thoughts Definition of Radiology Radiology is a medical specialty using medical imaging technologies to diagnose and treat patients. So what does this mean? We do NOT spend all day in a small dark room staring at a computer screen ….just most of the day A widely varied discipline Read a chest x ray Stage lymphoma Do a TIPS procedure Do a biopsy (lung, bone, thyroid, breast…) Inject a joint Do a barium swallow With multiple subspecialties Breast Body Neuro MSK Peds IR What our are tools? X-rays CT MRI Ultrasound Nuc Medicine Fluoroscopy Mammography Conventional Radiography “X-Ray” Lingo: Density Opacity Observable Densities: Metal Bone Soft Tissue Gas Computed Tomography (CT) Lingo: Hounsfield Units Attenuation Density Enhancement -1000 air *** -100 fat 0 water *** 20-80 soft tissues 100’s bone/Ca/contrast >1000’s metal Large radiation dose Nuclear Medicine (NM) Lingo: Physiologic imaging Radionuclides (Technetium) Radiopharmaceuticals Counts or Activity (Choletec) Radioactivity stays with the patient until cleared or decayed Ultrasound Lingo Echogenicity Shadowing Doppler for flow No radiation Can be portable Relatively inexpensive Magnetic Resonance Imaging (MRI) Lingo: No radiation Strong magnetic field Signal intensity T1 T2 Enhancement No pacemakers No electronic implants Small, loud tube Patients must hold still Relatively expensive Fluoroscopy Lingo Filling defect Density Opacity Real time information Radiation dose dependent on length of exam http://www.med-ed.virginia.edu/courses/rad/gi/index.html Mammography http://www.mdgrant.com/images/NormalMammogram.jpg Lingo Microcalcifications Mass Asymmetric density Screening exam consisting of 2 views recommended yearly for women over 50 We still recommend it! When will you interact with Radiology? Anytime you read a report on a study As a part of rounds (critical care and ID rotations in particular) When we call you up to ask about more information before we do a study When you call us to ask about which study should be done And if you want more… Rad 401 elective is a great way to get a broad introduction to radiology. Very helpful for people not interested in pursuing a career in radiology (plus those who are!) Pediatric radiology rotation Neuroradiology rotation Choose your own adventure…. How can you help us help you? Indication, indication, indication How will this study impact your clinical decision making? If it won’t, perhaps its useful to rethink the need for the study. Become adept at how to read basic studies (chest and abdominal films for line and tube placement in particular) Why is indication so important? It provides a paradigm for the picture we are reading. More information will help tailor the report to your clinical question. Depending on the indication, the hospital may not be reimbursed for the study GOOD BAD dyspnea in cancer patient R/O PE abdominal pain in Crohn’s patient s/p SB resection R/O pain Pain over dorsal aspect of trauma hand Contrast Oral contrast is frequently used in CT of the abdomen and pelvis and is very safe There are 2 types of intravenous contrast. Iodinated contrast for CT Gadolinium based contrast for MRI Radiologists like contrast !! BUT Contrast is not without risks Allergic Reactions to iodinated contrast Can range from mild to severe (hives to anaphylaxis) If mild allergic reaction, can pretreat with prednisone (50mg administered 13, 7, and 1 h prior to scan + Benadryl 1 hour before the scan) If severe allergic reaction, contrast is contraindicated! Iodinated contrast and renal failure Contraindicated in renal failure (acute and chronic) because of risk of contrast induced nephropathy (CIN); Strict UNC cut off is Cr of 1.8. Avoiding contrast in the setting of acute renal failure is important, but it is difficult for the radiologist, because the creatinine may be normal. (ie <1.8) In hyper-acute renal failure, the creatinine hasn’t risen yet. Decreased urine output or anuria is acute renal failure – regardless of the creatinine. Remember; first do no harm! Non-contrast studies can often be quite helpful. MR Contrast and NSF Risk of nephrogenic sclerosing fibrosis (NSF) increases with decreasing GFR; contraindicated <30 Progressive fibrosis of skin in patients with renal failure (typically on dialysis) which result in painful contractures and, possibly, death. http://jama.amaassn.org/content/vol297/issue3/images/medium/jmn60162fa.jpg Reading an abdominal film Where can you look at images PACS workstations ED ICUs WebCIS based PACS (java script) Web Based PACS Basics: Looking at Imaging Studies: Adequate Study? Correctly labeled with patient’s name, MR#, and the date of the study? Technically adequate? Systematic versus Focused look at a study: Radiologist does both! As the requesting clinician, you should also look at your patient’s study (at least plain films), as well as follow up on the final report. PTX, PNA, pleural effusions, SBO, free air Evaluate lines and tubes (especially the ones you placed!) Several different type of abdominal film series KUB (kidneys, ureter, bladder) 2 View---AP supine and erect abdomen Acute abdomen series: 2 view with upright chest Lateral decubitus (Left or Right) Cross table lateral---prone or supine Systematic process • Lines and tube (enteric tube, feeding tube, foley catheter, rectal tube, fem lines) • Bowel gas pattern (dilated loops, air where it shouldn’t be) • Visceral contours (hepatomegaly, abnormal soft tissue mass) •Abnormal calcifications (gallstones, kidney stones) • Bones Enteric tube (NG/OG) placement Tip AND sidehole need to be within the stomach body for proper suction REALLY BAD – enteric tube in lung http://icvts.ctsnetjournals.org/content/vol4/issue5/images/large/429fig1.jpeg Small Bowel Obstruction (SBO) Gasless abdomen if bowel loops are fluid filled Dilated small bowel loops (>3cm) Sometimes difficult to differentiate between SBO and ileus (both colon and small bowel tend to be dilated) http://archive.student.bmj.com/issues/02/04/education/102.php Paucity of gas CT correlate: SBO Dilated loops of small bowel CT correlate: more gas, & SBO Pneumoperitoneum Pneumoperitoneum Abnormal calcifications: Gallstones supine and erect Air-fluid levels CT correlate: Gallstones Abnormal Calcifications: Nephrolithiasis CT correlate: Nephrolithiasis Abnormal calcifications: Appendocolith http://www.hawaii.edu/medicine/pediatrics/pemxray/v6c18.html Plain film imaging of the Abdomen: Bones http://www.szote.u-szeged.hu/radio/trauma2/a2trau3a.htm Radiology at UNC The Department of Radiology at the University of North Carolina at Chapel Hill has eight clinical sections: Abdominal Imaging (Body CT, US, MRI, Flouro studies such as UGI and SBFT, Biopsies) Breast Imaging Cardiopulmonary Imaging (Chest, Cardiac) Musculoskeletal Imaging (Bone, ER RR, MSK MRI’s) Neuroradiology (brain/spine CT & MRI; lumbar punctures) Nuclear Medicine (wide variety, PET-CT, bone scans, Cards) Pediatric Imaging (wide variety) Vascular-Interventional (wide variety) Calling Radiology Try to call the right reading room (RR). Each subspecialty has their own reading room Calling the Neuro reading room to talk about a chest x ray will not get you far (like asking ENT to perform an appendectomy) When paging, it’s nice to put your name/pager number immediately after the call back number After hours: 6-8850 Lower Level/ER RR 216-2826 Upper Level (VIR, Doppler US, MRI) DON’T call 6-8850 during the day unless it’s an MSK radiology issue When you call, identify yourself, and expect whoever answers to identify themselves. Improves accountability Always good policy to know who talked to Please page us if our report is confusing! Parting thoughts (for Radiology and beyond!) Always try to be polite. This will be difficult when you are sleep deprived and overworked, but “please” and “thank you” go a long way in maintaining cordial relationships with your coworkers. Try to resist the urge to “bad mouth” other specialties. Speak up when you see something wrong! RECAP o Radiology is a cool specialty. Think whether it’s a good fit as you go through the year. o CT is a great tool but provides a high does of radiation o Provide good indications! o IV Contrast + Sick Kidneys = BAD o If worried about free air in the abdomen, order upright or decubitus films Thanks for listening! Questions? Hx: Please Evaluate New Line. “?!@#!%!”