Radiation diagnosis of chest injuries. Algorithms for radiation research methods
Radiation diagnostics for traumaRadiation diagnostics plays an important role in the initial examination of patients with trauma and determining the tactics of EMT. The main method of radiation diagnostics used at this stage is radiography. However, many trauma centers are increasingly using other methods, such as spiral CT, angiography and RT, to make a definitive diagnosis and exclude injuries. Improvements in radiation diagnostic methods have made it possible to increase the accuracy of the information obtained and reduce the examination time, and the development of endovascular treatment methods has created an alternative to traditional surgical interventions for some vascular injuries.
The choice of radiation diagnostic method is individual and depends on a number of factors, which are listed below.
- Availability of equipment to conduct a particular study and its proximity to the place where EM P is provided.
- Quality and speed of obtaining information using existing equipment.
- Availability of specialists in radiation diagnostics and their experience in conducting emergency studies.
- Availability of specialists who can analyze the information received.
- The ability to timely transfer research results to other specialists.
- The ability to monitor basic physiological indicators, maintain vital functions, including carrying out resuscitation measures, in the event of a sudden deterioration in the patient’s condition during transportation to the study site or during the study itself.
The main factor determining the possibility of conducting the study and its duration is the patient’s hemodynamic stability. In case of severe shock and the ineffectiveness of the first stage of EMT, any research may be unsafe. The only test that can be done is a bedside ultrasound to detect fluid in the body cavities. If the patient is admitted in a state of shock, but his treatment is effective, bedside radiography of the chest, pelvis and spine can be performed, while transporting him to other departments for CT or MRI is dangerous. With initially stable hemodynamics and no deterioration of the patient's condition, CT or MRI can be performed if necessary at the first stage of EMT. Optimal use of diagnostic imaging techniques requires close collaboration and collaboration between trauma surgeons, nurses, and research staff. A radiodiagnostic specialist can and should help the trauma surgeon select the necessary studies and determine their order in order to answer the questions that arise in a particular clinical situation as fully as possible.
RADIATION DIAGNOSIS FOR CHEST TRAUMA
Chest X-ray in the posterior direct projection allows you to accurately diagnose pneumothorax, including tension pneumothorax, pneumomediastinum, pneumopericardium, contusion, a; m. Mechanical damage to the body without violating the integrity of the outer integument, accompanied by rupture of small vessels and hemorrhage, disruption of the integrity of subcutaneous tissue, muscle fibers, and sometimes internal. organs (liver, spleen, etc.).
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Urgent Care. After excluding possible damage to internal organs, anti-shock therapy is carried out.
Chest compression possible in case of industrial accidents, car injuries and other situations. The diagnosis is made based on the signs of so-called traumatic asphyxia: the head, face and chest of the victim acquire a purple-purple color with a sharply defined lower border. Petechial rashes are observed on the skin and visible mucous membranes.
Urgent Care. Relief of pain syndrome. Oxygen therapy. Symptomatic therapy. Urgent hospitalization in a surgical hospital.
Rib fractures occur with a blow, fall, compression of the chest and can be single or multiple, with or without displacement. When displaced, complications are possible in the form of damage to intercostal vessels and nerves, pleura and lung, with the formation of various types of pneumothorax, hemothorax, and subcutaneous emphysema.
Diagnostics is based on anamnesis, localized pain syndrome associated with breathing, chest movements, and coughing. Reliable signs of a rib fracture include the presence of pathological mobility of rib fragments, crepitus of bone fragments and deformation of the chest (in case of multiple fractures). With multiple fractures, a shock state with signs of stage I-III ARF may develop.
The leading additional method for diagnosing rib fractures is chest radiography. It should be noted once again that a negative response to X-ray examination does not exclude the presence of rib fractures.
Urgent Care. An intercostal novocaine or alcohol-novocaine blockade is performed at the fracture site. Oxygen therapy. If there are signs of shock, antishock therapy is prescribed. Urgent hospitalization in the surgical department.
Sternum fracture usually occurs at the border of its body and the manubrium or xiphoid process. There is typical localized pain associated with breathing. Differential diagnosis is made, first of all, with ischemic heart disease.
Urgent Care: pain relief is performed intramuscularly or intravenously by administering 2-4 ml of 50% analgin solution. For severe pain, novocaine or alcohol-novocaine blockade at the fracture site is indicated. Surgeon consultation.
4.8. Long-term compartment syndrome,principles of treatment (crash syndrome):
The principles of treatment for SDS are most successfully formulated by R. N. Lebedeva et al. (1995):
Support of blood circulation and respiration (correction of volume, cardiotonics, catecholamines, blood components, mechanical ventilation);
Timely surgical and trauma care (fasciotomy, necrectomy, osteosynthesis, amputation of limbs, plastic surgery of tissue defects);
Correction of acid-base balance, water-electrolyte balance;
Detoxification (hemodialysis, hemofiltration, ultrafiltration, hemosorption, hepatoprotectors);
Analgesia, anesthesia, psychotropic therapy;
Hyperbaric oxygenation;
Enteral and parenteral nutrition.
Note. 1. When the blood pH is below 6.0, renal block occurs (Lalich J., 1955). In these cases, free hemoglobin in the plasma begins to transform into hematin hydrochloride, which is retained in the tubules, which contributes to the formation myoglobinuric nephrosis, which is not observed with alkaline urine. Prevention of this complication is achieved by alkalizing the plasma by intravenous drip administration of 4% sodium bicarbonate solution until an alkaline urine reaction is obtained.
2. Correction of impaired rheological properties of blood is achieved by using heparin, trental, fibrinolytically active or fresh frozen plasma.
Scope of assistance at the site of injury. Before freeing those affected from the rubble, it is necessary to prevent ischemic toxicosis in the following sequence: pain relief with analgesics, administration of alkaline blood substitutes into a vein or per os to prevent blockage of the renal tubules by myoglobin crystals formed during reperfusion against the background of acidosis. In order to prevent ischemic toxins from entering the bloodstream, it is then necessary to apply a tourniquet proximal to the site of compression. After this, the affected person is released, taken to a safe place and the tourniquet is replaced with a tight bandage of the compressed tissues of the limb, and the compressed areas of the body are covered with bags of coolant. This is necessary to restore blood flow in compressed tissues in a limited, gentle manner, as well as in ischemic tissues, which makes it possible to prevent their destruction, toxicosis and reactive hyperemia. The entire scope of prehospital care ends with tissue cooling and transport immobilization.
4.9. Limb injuries in the wounded, the affected are divided into open and closed. Among the latter, a distinction is made between firearms and non-firearms. Both open and closed injuries are divided into three groups: muscle tissue damage, bone fractures, joint damage. Signs of a bone fracture are: severe pain (local pain that intensifies with the slightest movement); deformation of a limb segment; pathological mobility and crepitus in the fracture area; presence of swelling. Gunshot fractures are divided into incomplete and complete. Among the latter, there are transverse, longitudinal, oblique, and crushed. Among the fractures of long tubular bones, there are comminuted and comminuted fractures. Recognizing them is not very difficult - with these fractures the following are noted: deformation of the limb, pathological mobility, crepitus in the area of the fracture.
The sequence of provision of first medical aid, pre-medical aid, first medical aid at the primary care facility to the wounded, those affected by fractures of the extremities is as follows:
· pain relief;
· applying an aseptic bandage to the wound, cleaning the wound (hydrogen peroxide, chlorhyxidine, etc.), using a “cimesol” aerosol, which can be used to stop the development of wound infection for up to 2-3 days;
· transport immobilization with fixation of two adjacent segments of the injured limb.
Before applying splints to exposed limbs, they should be wrapped in cotton-gauze pads. Immobilizing splints must be attached with bandages along the entire length of the limb. The main danger when bandaging is constriction of the limb. In the cold season, after applying a splint, the limb must be insulated.
During transport immobilization of injured limbs, splints can be applied over clothing and shoes.
Methods of transport immobilization depend on the location of the injury.
For shoulder fractures, the upper limb is immobilized using a pre-modeled ladder splint (Kramer splint), which is applied from the base of the fingers to the shoulder girdle of the healthy side. The forearm is bent at the elbow joint at an angle of 90° and fixed in the middle position between pronation and supination. The shoulder is brought forward 30° and slightly away from the body. The proximal end of the splint is connected to the distal end with two gauze straps covering the chest on the side of the body opposite the fracture from the front and back. The splint is fixed with a gauze bandage.
For forearm fractures, a scalene splint is applied from the upper third of the shoulder to the metacarpophalangeal joints. The forearm is fixed in the same position as for shoulder fractures. Additionally, a scarf is used.
For shin fractures, three ladder splints are applied: a back splint, modeled according to the contours of the calf muscles and heel, and two tibia splints. For all fractures of the lower extremities, the foot is fixed in dorsiflexion at an angle of 90°.
In case of hip fractures, the entire lower limb is immobilized with a Dieterichs splint; before applying the splint, both periostems, which rest against the affected person in the axillary and inguinal-perineal region, as well as the inner surface of the branches, must be wrapped in cotton wool, then the injured limb is stretched along its length, eliminating rotational displacement by twisting on a plywood sole. The splint is attached to the body with cloth bandages.
To immobilize hip fractures and multiple fractures, you can use the Kashtan anti-shock suit, which provides a traction splint for both limbs and the pelvis at once and provides traction along the length of the limb up to 12 kg.
In addition to the listed splints, three types of plastic splints are used to immobilize damaged bones: 1st type - width 115 mm, length 900-1300 mm - for the lower leg; Type 2 - width 100 mm, length 900-1300 mm - for the upper limb and type 3 - width 100 mm, length 750-1100 mm - for children. Various types of splints and combined dressings can be used as means for therapeutic and transport immobilization.
In table 5. Data on the sequence of identifying the nature of injuries and emergency measures at the prehospital stage have been consolidated into a single system.
Table 5. Identification of the nature of the damage to the affected person and
emergency medical care at the scene of the incident
| Subsequence inspection and detection of damage | Objective data, clinical manifestations | Emergency medical care |
| Determining the integrity of blood vessels | - pale face - ineffective attempt to inhale - vomit on the face - obstruction to breathing in the oral cavity (foreign body) | - cleaning the oral cavity, removing a foreign body - tracheal intubation, - artificial ventilation |
| 1. Examination of the head and spine: - craniocerebral injuries, gunshot and non-gunshot wounds: soft tissues; non-penetrating, penetrating injuries of the skull and brain | - damage to the skin, aponeurosis, muscles, periosteum, hematoma - damage to soft tissues, bones with the integrity of the dura mater - fractures of the vault, base of the skull | - stopping external bleeding - cold on the head - aseptic bandage - cordiamine or caffeine solution - lytic mixture: |
| - damage to all membranes and the brain - bleeding from the ear, nose - unilateral, bilateral exophthalmos - respiratory rhythm disturbance - absence of corneal reflexes, wandering eyeballs - damage to the brain stem. | aminazine - 2% 2.0 ml, diphenhydramine - 2% 1.0 ml furosemide - 2.0 ml atropine - 0.1% 1.0 ml | |
| - spine and spinal cord: soft tissue injury; penetrating spinal injuries with spinal cord injury | - damage to soft tissues, muscles, vertebral bodies - identification of motor disorders, trophic disorders, pelvic disorders | - stopping external bleeding, aseptic dressing - anesthesia of the cervicothoracic spine - transport immobilization |
| - maxillofacial area | - deformation of the lower jaw, retraction of the chin, malocclusion, separation and displacement of the alveolar process - fracture of the body of the upper jaw, - separation of the upper jaw - bleeding | - anesthesia - aseptic dressing - tongue fixation - immobilization |
| 2. Examination of the chest: non-gunshot and gunshot, penetrating and non-penetrating with damage to the ribs, scapula; multiple rib fractures | - shortness of breath, suffocation, hemoptysis, open bilateral pneumothorax, frequent shallow breathing - SBP is reduced, pulse is frequent and soft - valvular pneumothorax - emphysema of the face, neck, mediastinum and the occurrence of tension pneumothorax - hemothorax | - puncture of the pleural cavity is carried out in the 2-3 intercostal space along the midclavicular line with connection of the petal valve - anesthesia - vagosympathetic blockade novocaine solution - 0.25% 60 ml for PMP - cardiac |
| 3. Examination of the abdomen, penetrating and non-penetrating; bullet and fragmentation through, blind, tangential with damage to hollow organs, intestines, stomach; parenchymal organs - liver, spleen and mesentery; injury to the kidneys and ureters | - dry tongue - muscle tension in the abdominal wall - bloating, positive Shchetkin-Blumberg sign - absence of noise on auscultation of the abdomen - dullness on percussion of the lumbar region due to retroperitoneal hematoma - hemoperitoneum - shock - hematuria | |
| 4. Examination of the pelvis and pelvic organs: gunshot and non-gunshot; with damage to the pelvic bones and bladder; rectum, posterior urethra, prostate gland | - tension in the muscles of the abdominal wall - hematuria - penetration of urine into the wound - exit of feces through the wound - deformation of the pelvis - presence of a defect in the pubic area | - aseptic dressing - pain relief - cardiac - bladder catheterization |
| 5. Inspection of extremities, gunshot and non-gunshot; with damage to soft tissues, joints | - pathological mobility - bone crepitus - visible deformation of the limb in the area of the fracture of the diaphysis and epiphysis - shock of III-IV degree SBP below 70 mm Hg. Art. - blood loss depends on the fracture of the upper or lower limb and will be from 1.5 to 3 l | for wounds: - aseptic dressing - anesthesia - immobilization of limbs |
| 6. Massive detachment of skin and fiber | - softening in subcutaneous tissue | - aseptic dressing |
4.10. Under polytrauma understand multiple or combined injuries that pose a danger to the life or health of the injured person and require emergency medical care.
Pre-medical, first medical aid for polytrauma at the scene of an incident includes:
· restoration of patency of the upper respiratory tract;
· stopping external bleeding by applying an aseptic bandage or tourniquet;
· pain relief;
· immobilization of fractures with standard splints;
· infusion therapy for shock, SDS, burns;
· preparing the injured for evacuation.
At the scene of the incident, when examining and sorting the injured, two groups are distinguished - those who are conscious and those who are unconscious. Among those who are conscious, they determine who needs emergency medical care in specialized and general surgical departments and those for whom assistance after first medical aid may be delayed, they are evacuated secondarily to general surgical departments. Those who are unconscious and those who do not return to consciousness after first medical aid are evacuated first, lying on their sides, to the next stage.
4.11. Under combined lesions It is customary to understand damage resulting from the action of several damaging factors - mechanical, thermal, chemical, radiation, cold.
Combined mechanical-thermal damage occurs under the influence of mechanical and thermal factors with the predominant action of the mechanical factor. In patients with combined thermomechanical lesions, traumatic and burn shock most often develops and is severe. Based on the severity, combined thermomechanical damage can be divided into four groups (Table 6).
Table 6. Classification of mechanical and thermal damage
by severity
| Severity of injury | Burn severity | Mechanical damage |
| Lightweight | I-III A (up to 10% of the body surface), III B – IV (up to 3% of the body surface) | Bruises, sprains, skin wounds, isolated injuries to small bones of the limb, clavicle fractures. Mild concussion |
| Average | I – III A (10 - 20% of the body surface), III B – IV (up to 10% of the body surface) | Wounds with tendon damage and a large area of soft tissue damage. Dislocations in large joints of the limbs, avulsion fractures of the ribs, pelvic bones, and one of the paired tubular bones. Open fractures of the bones of the foot. Isolated spinal fractures. Compression, moderate to severe concussion |
| heavy | I - III A (20 - 30% of the body surface); III B – IV (10 - 20% of body surface) | Injury of soft tissues with damage to nerves and opening of large joints. Closed multiple fractures of the pelvis and limbs. Open isolated fractures of large limb bones with a small area of soft tissue damage. Spinal fractures with damage to the spinal cord, fractures of the skull bones. Limb compression |
| Extremely heavy | I – III A (31 – 50% of the body surface); III B-IV (more than 20% of body surface) | Wound with damage to the great vessels. Open fractures with an extensive area of soft tissue damage. Open intra-articular fractures. Traumatic amputations of limbs. Multiple fractures of the pelvic bones. Fractures of the cervical spine with damage to the spinal cord. Multiple fractures of the skull bones and its base. |
Urgent pre-medical and first aid measures for combined mechanical-thermal injuries of the affected person include:
· stop bleeding by applying an aseptic bandage, ligating a bleeding vessel;
· in exceptional cases and for a minimally short time - apply a tourniquet to the burned limb;
· tracheostomy for severe burns of the upper respiratory tract, intubation with an airway;
· cutting off non-viable burned limbs hanging on a skin flap;
· applying an aseptic dressing to the burned surface;
· with a burn surface of no more than 1% of the body surface - irrigation with chlorethyl, aseptic bandage after toileting the wound;
· evacuation of the injured person to the next stage.
Principles of treatment of burn shock
After pain relief, in the treatment of burn shock, as well as traumatic shock, infusion therapy comes first. Its duration and volume depend on the degree of the burn, its surface and the state of the body’s protective and adaptive functions. Infusion therapy for the treatment of burn shock is presented in Table. 7.
Table 7. Transfusion therapy program for burn shock
(V. A. Klimansky, Y. A. Rudaev, 1984)
According to the protocol ATLS(life support for victims in the first hours of injury) when a spinal injury is suspected, an initial clinical assessment should precede an appropriate radiological examination. As follows from publications, non-contact multilevel spinal injuries occur in 4.5-16.7% of all cases of spinal column injury.
proper imaging study allows you to determine the nature of the damage and avoid untimely diagnosis and medical care. X-ray assessment of the cervical spine begins with a lateral “cross table” (horizontal direction of the X-ray beam; the patient is in a horizontal supine position) projection (CTLV), which can detect 70-79% of all injuries.
side shot should depict the entire cervical spine, including the cervicothoracic junction. Adding images in the anteroposterior projection and images through the mouth increases the effectiveness of plain radiography to 90-95%. Damage to the cervical spine mainly affects the C2 vertebra and the C5-C6 motor segment.
Diagnosis of instability Radiography with load flexion-extension tests greatly contributes, but in emergency situations it cannot be considered as the method of choice. In most cases, due to muscle spasm, patients with acute injury are unable to voluntarily and fully perform flexion and extension of the spine.
With negative results of survey images and persistent clinical symptoms, functional radiography is prescribed 2-3 weeks after injury.
All patients with multiple injury, with impaired consciousness or neurological disorders, an x-ray of the thoracic and lumbar spine is indicated. The sensitivity of imaging studies is enhanced by the use of helical CT. The combination of plain radiography with helical CT has proven to be a fast and sensitive way to diagnose cervical spine injuries in mentally disturbed patients.
CT are used for more distinct visualization of transition zones that are difficult for X-ray diagnosis and clarification of the area of damage assumed on the basis of radiographs.
Urgent implementation CT it is necessary in all cases of obtaining radiographs that do not correspond to clinical symptoms or do not allow to come to an unambiguous conclusion. On an emergency basis, a CT scan of the head is performed for all patients with impaired neurological status due to a closed craniocerebral injury, and if necessary, the study area can be expanded to include the cervical spine.
Urgent execution MRI indicated for all patients with neurological deficits, inconsistent levels of skeletal and neurological injury, and progression of neurological disorders. Despite the negative results of the survey images, MRI may be indispensable for determining damage to the posterior ligamentous structures. However, MRI is not routine for polytrauma, as these patients often require assistive devices (breathing equipment, limb immobilization splints, IV pumps) that can affect the magnetic field.
- 1. ALGORITHMS OF RADIATION METHODS Prof. B.N. Sapranov Izhevsk State Medical Academy Course of Radiation Diagnostics and Radiation Therapy Prof.
- - Standard..." target="_blank"> 2. LEVELS OF RADIATION INVESTIGATION ALGORITHMS
- - Standard radiography
- - General ultrasound
- - Linear tomography
- TV fluoroscopy
- - All level I techniques
- - Special radiography techniques
- - Special Ultrasound techniques, including Dopplerography
- - Mammography
- - Osteodensitometry
- - Angiography
- - CT
- - Radionuclide methods
- - All level I and II techniques
- - MRI
- - PET
- - Immunoscintigraphy
- Informative..." target="_blank"> 3. Principles for choosing a visualization method
- Information content
- Lowest radiation exposure
- Minimum cost
- Radiologist qualification
- Diseases..." target="_blank"> 4. Headache syndrome Main causes
- Central nervous system diseases
- KVO anomalies
- Hypertonic disease
- Vertebro-basilar insufficiency
- Level I Skull X-ray
- Normal Intracranial Intracranial hypertension calcification
- X-ray of the cervical
- spine
- Level II CT, MRI CT, MRI CT
- 6. Intracranial calcifications MeduMed.Org - Medicine - Our Vocation
- 8. Lateral synostosis and spondylolysis C6-C7
- ORGANS OF THE THORACIC CAVITY MeduMed.Org - Honey..." target="_blank"> 9.
- ORGANS OF THE THORACIC CAVITY
- Acute pneumonia
- Acute pleurisy..." target="_blank"> 10.
- Acute pneumonia
- Acute pleurisy
- Spontaneous pneumothorax
- TELA
- Acute abdomen (appendicitis, cholecystitis)
- Pathology of the skeletal system
- 11. Algorithm for radiation examination for acute chest pain syndrome of non-cardiac localization. NORMAL PAT.BONE? ESOPHAGUS PATTERN? PNEUMOTHORAX? TELA? MEDIASTINUM? PLEURISY? PRINCIPLE IMAGE CONTRAST CONTROL-DELAYED LIN.TOMOGR. INVESTIGATION GRAPHIC IMAGING ULTRASOUND Lv. II CT CT APG SKELETON SCINTIGRAPHY MeduMed.Org - Medicine - Our Vocation
- 12. Acute pleurisy
- 13. Acute pneumonia MeduMed.Org - Medicine is Our Vocation
- 14. Lung infarction MeduMed.Org - Medicine is Our Vocation
- 15. Small pneumothorax MeduMed.Org - Medicine - Our Vocation
- 16. Rib fractures in multiple myeloma
- 17. Acute pain in the chest of cardiac localization (first of all, it is necessary to exclude AMI) Main causes
- Dissecting aortic aneurysm
- TELA
- Acute pericarditis
- Acute pleurisy
- Reflux esophagitis
- Diaphragmatic hernia incarceration
- Acute abdomen (gastric ulcer perforation, cholecystitis).
- 18. Algorithm of radiological examination for acute pain in the chest of cardiac localization
- Level I ultrasound (sonography)
- 19. Coronary sclerosis MeduMed.Org - Medicine - Our Vocation
- 20. Diaphragmatic hernia MeduMed.Org - Medicine - Our Vocation
- Main reasons
- 1) IHD
- 2) Cardiomyopathy
- 3) Dry pericarditis
- 4) Stenosis of the aortic mouth
- 5) Diseases of the lungs and diaphragm
- 6) Reflux esophagitis
- 7) Axial hiatal hernia
- 8) Relaxation of the diaphragm
- 9) Intercostal neuralgia
- 22. Algorithm for radiation examination for chronic pain in the heart area
- Level I Chest X-ray, Ultrasound
- No changes Changes detected Lungs Heart Aortic aneurysm
- Ultrasound of the abdomen See diagrams X-ray. gr. class delayed Lv. II XRD of the esophagus, Doppler of the stomach ACG, Aortography Coronary angiography. CT with contrast.
- Level III
- MRI
- 23. Hypostasis of the lungs MeduMed.Org - Medicine - Our Vocation
- 24. Left ventricular aneurysm MeduMed.Org - Medicine - Our Vocation
- 25. Aortic aneurysm MeduMed.Org - Medicine - Our Vocation
- 26. Cardiomegaly
- 27. Aortic stenosis
- 28. Constrictive pericarditis MeduMed.Org - Medicine - Our Vocation
- 29. Relaxation of the diaphragm
- Main reasons
- 1) COPD<..." target="_blank">30. Shortness of breath
- Main reasons
- 1) COPD
- 2) Airway obstruction (intrabronchial tumors, mediastinal lymphadenopathy)
- 3) TELA
- 4) Heart diseases
- 5) Diffuse interstitial focal lung diseases (toxic and allergic alveolitis, fibrosing alveolitis, pneumoconiosis, multiple metastases)
- 6) Primary pulmonary hypertension
- 7) Anemia
- 8) Obesity
- Level..." target="_blank"> 31. Algorithm for radiation examination for shortness of breath
- Level I CHEST X-RAY
- 32. Emphysema
- 33. Wegener's granulomatosis
- 34. Primary pulmonary hypertension
- 35. Foreign body in the bronchus
- 36. Exogenous alveolitis
- 37. Scleroderma MeduMed.Org - Medicine - Our Vocation
- 38. Scleroderma
- 39. Pulmonary berylliosis
- 40. Sarcoidosis of the lungs MeduMed.Org - Medicine - Our Vocation
- 41. TELA MeduMed.Org - Medicine - Our Vocation
- 42. Lymphadenopathy of the mediastinum MeduMed.Org - Medicine - Our Vocation
- Main reasons
- Main reasons
- 1) Pulmonary tuberculosis
- 2) COPD (chronic bronchitis, bronchiectasis)
- 3) Central lung cancer
- 4) Compression of the trachea and main bronchi (tumorous lymphadenopathy, viral bronchoadenitis)
- 5) Lung abnormalities
- Level I Chest X-ray Diagnosis is clear Diagnosis is unclear Linear tomography Functional radiography (Sokolov test)
- Level II CT, APG
- 45. Hematogenously disseminated pulmonary tuberculosis
- 46. Bronchiectasis
- 47. Bronchiectasis
- 48. Broncholithiasis MeduMed.Org - Medicine - Our Vocation
- 49. Chronic bronchitis stage I. MeduMed.Org - Medicine - Our Vocation
- 50. Chronic bronchitis stage III.
- 51. Central lung cancer MeduMed.Org - Medicine - Our Vocation
- 52. Hypoplasia of the left pulmonary artery MeduMed.Org - Medicine - Our Vocation
- The main reasons..." target="_blank"> 53. Hemoptysis and pulmonary hemorrhage
- Main reasons
- 1) Lung tumors (central cancer, bronchial adenoma)
- 2) PE, pulmonary infarction
- 3) Lobar pneumonia
- 4) Pulmonary tuberculosis
- 5) Lung anomalies (AVA, varicose veins)
- 6) Aspergillosis
- 7) Hemosiderosis (congenital, heart disease)
- 54. Algorithm of radiological examination for hemoptysis and pulmonary hemorrhage
- Level I Chest X-ray Source established Not established Peripheral. TELA? delayed snapshot
- Level II CT APG
- 55. Tuberculous cavern MeduMed.Org - Medicine is Our Vocation
- 56. Pulmonary Aspergillosis MeduMed.Org - Medicine is Our Vocation
- 57. Varicose veins of the lung MeduMed.Org - Medicine - Our Vocation
- 58. Peripheral cancer in the decay phase
- 59. Abdominal organs MeduMed.Org - Medicine - Our Vocation
- Main reasons
- 1) ..." target="_blank"> 60. Acute stomach
- Main reasons
- 1) Perforation of a hollow organ
- 2) Intestinal obstruction
- 3) Acute appendicitis
- 4) Gallstone disease
- 5) Acute pancreatitis
- 6) Abdominal abscess
- 7) Renal colic
- 61. Algorithm for radiation examination for acute abdomen syndrome
- Level I Plain X-ray of the abdomen, ultrasound The picture is clear The picture is not clear
- Laterogram
- Level II X-ray contrast study, CT
- 62. Perforation of a hollow organ MeduMed.Org - Medicine - Our Vocation
- 63. Intestinal obstruction MeduMed.Org - Medicine - Our Vocation
- 64. Right-sided subphrenic abscess MeduMed.Org - Medicine - Our Vocation
- 65. Acute appendicitis
- 66. Thrombosis of mesenteric vessels
- <..." target="_blank">43. Chronic cough
CHAPTER 3 RADIATION DIAGNOSIS OF DISEASES OF THE CHEST CAVITY ORGANS
CHAPTER 3 RADIATION DIAGNOSIS OF DISEASES OF THE CHEST CAVITY ORGANS
JUSTIFICATION OF THE NEED FOR STUDYING THE TOPIC
It should be noted that the same clinical symptoms of lung diseases (fever, cough, shortness of breath, chest pain, hemoptysis, etc.) occur with many pathological changes, which causes difficulties in differential diagnosis.
In order to correctly make a diagnosis, the attending physician must first prescribe an X-ray examination of the lungs, which remains the main diagnostic method. The information content of X-ray and other radiation methods in diagnosing a particular lung disease will be discussed in this chapter.
SUPPORTING MATERIAL
The following material is presented in the form of fundamental questions and answers to them. They will help in obtaining the necessary information about the x-ray anatomy of organs.
chest cavity, about radiation methods and techniques, about their informativeness in various diseases of the lungs and mediastinum, about x-ray semiotics of the main pathological conditions and their differential diagnosis.
Fundamental questions and answers
Question 1. What do the organs of the thoracic cavity look like on radiographs in direct projection?
Answer.In direct projection, the right and left lungs look like clearing due to air in the alveoli, and the shadow of the mediastinum is visible between them (this is called natural contrast).
Against the background of the lungs, the so-called pulmonary fields, shadows of the ribs, clavicles (above the clavicles of the apex of the lungs), as well as shadow stripes of blood vessels and bronchi forming pulmonary pattern, radiating fan-shaped from the roots of the lungs.
Shadows of the roots of the lungs adjacent on both sides to the shadow of the middle mediastinum. The roots of the lungs are formed by large vessels and lymph nodes, which determines their structure. The root has a head (proximal part), a body and a tail, the length of the root is from the II to IV ribs at the anterior ends, its width is 2-2.5 cm.
Mediastinal shadow has three departments:
Upper (to the level of the aortic arch);
Medium (at the level of the aortic arch, where the thymus gland is located in children);
Bottom (heart).
Normally, 1/3 of the shadow of the lower mediastinum is to the right of the spine, and 2/3 is to the left (this is the left ventricle of the heart).
The lungs are limited below diaphragm, each half of it has a dome-shaped shape, located at the level of the VI rib (1-2 cm lower on the left).
Pleura forms in direct projection the right and left costophrenic and cardiophrenic sinuses, which normally give triangular-shaped clearing.
Question 2. Are there any features in the shadow picture of the thoracic cavity organs in the lateral projection?
Answer. In the shadow picture of the organs of the chest cavity in the lateral projection, the peculiarities are that both lungs are layered on top of each other, so this projection cannot be analyzed independently,
and must be combined with direct projection in order to present a planar image as three-dimensional.
It is necessary to make two lateral projections (left and right): in this case, the half of the chest that is adjacent to the film is better visible.
Against the background of the pulmonary fields are visualized shadows of bone formations: in front - the sternum, behind - the III-IX thoracic vertebrae and scapula, the ribs run in an oblique direction from top to bottom.
Pulmonary field visible in the form of enlightenment, which is divided into two triangles, separated by the shadow of the heart, which reaches almost to the sternum:
Upper - retrosternal (behind the sternum);
The lower one is retrocardial (behind the shadow of the heart).
root shadow the corresponding side (in the right lateral projection - the right root) is visible in the center of the image against the background of the middle mediastinum. Here the wide ribbon-like clearing of the trachea, coming from the neck, breaks off, since in the root area the trachea is divided into bronchi.
Sinuses of the pleura in the form of triangular clearings, limited below by the diaphragm, in front by the sternum, behind by the spine, these are the anterior and posterior:
Cardio-diaphragmatic;
Costophrenic.
Question 3. How many lobes and segments are there in the right and left lung? What are the different interlobar fissures on direct and lateral radiographs of the lungs and what is their projection?
Answer. Number of lobes and segments of the lungs:
The right lung has 3 lobes (upper, middle, lower) and 10 segments;
The left has 2 lobes (upper, lower) and 9 segments (no VII). There are oblique and horizontal interlobar fissures.
The oblique interlobar fissure separates:
The upper lobe is to the right of the lower and middle lobes;
To the left - from the lower lobe;
The course of the slit depends on the projection;
In a direct projection, it goes from the spinous process of the III thoracic vertebra to the outer part of the IV rib and further down to the highest point of the diaphragm (in its middle third);
In the lateral projection, it passes from above (from the third thoracic vertebra) through the root down to the highest point of the diaphragm.
The horizontal fissure is located on the right, it separates the upper lobe from the middle lobe:
In direct projection, its course is horizontal from the outer edge of the IV rib to the root;
In the lateral projection, it departs from the oblique fissure at the level of the root and goes horizontally to the sternum.
Question 4. What is the algorithm for using radiation methods and techniques for diseases of the chest organs and what are the purposes of their use?
Answer. For diseases of the chest cavity algorithm for using ray methods and techniques next.
X-ray examination
- Fluorography lungs - a preventive diagnostic method; are used once a year in the entire population, starting from the age of 15, to detect tuberculosis, early forms of cancer and other diseases.
- X-ray organs of the chest cavity gives an idea of their functional state:
Respiratory movements of the ribs and diaphragm;
Displacements and changes in the shape of the pathological shadow during breathing;
Shadow pulsations with vascular formations;
Changes in the pulmonary pattern when breathing;
Movement of fluid in pathological cavities and in the pleural cavity when changing body position;
Heart contractions.
Multi-axis polypositional examination ensures the selection of the optimal projection for radiography, including for targeted images
Fluoroscopy is used in interventional radiology, those. under her control, punctures of various formations of the chest cavity, cardiac angiography, etc. are performed.
- Survey radiography organs of the thoracic cavity in direct and lateral (right and left) projections allows:
Identify pathological changes;
Establish their localization;
Clarify the various symptoms of diseases of the lungs, pleura and mediastinum.
- Tomography- layer-by-layer longitudinal study, in two projections (direct and lateral), it contributes to:
Obtaining a clearer image of pathological shadows, as it relieves them of the layering of surrounding tissues;
Establishment of any morphological type of changes in the organs of the thoracic cavity;
Visualization of the bronchial lumen.
This technique is mandatory and most informative for all diseases of the thoracic cavity. It is usually carried out after a survey x-ray, in which the depth of the required tomographic slices is measured.
- Bronchography Thanks to the introduction of high-contrast substances into the bronchi, it allows you to visualize them and judge their condition. This technique is prescribed after tomography, in which it was not possible to see the lumen of the bronchus of interest.
- Angiopulmonography consists of introducing high-contrast substances into the vessels under fluoroscopy control, then radiography is performed in two projections and the resulting picture is analyzed. Technique: through the artery of the elbow, the catheter is passed further through the right atrium and right ventricle of the heart into the pulmonary trunk, the vessels of the lungs and heart are contrasted, and their condition is determined.
CT gives cross-sections of the organs of the chest cavity (transverse), while assessing the condition:
Alveoli;
Vessels;
Bronkhov;
Lymph nodes of the roots;
Anatomical structures of the mediastinum;
Density and other parameters of all anatomical and pathological structures.
Spiral computed tomography is the next stage in the development of the method, uses three projections (transverse, frontal, sagittal), and therefore is more informative in assessing the condition of the above objects.
Ultrasound lungs are currently practically not used due to the fact that research is hampered by air in the alveoli, therefore
Ultrasound is used mainly for examining the heart (see Chapter 2). In some cases, it allows to establish a neurinoma from the intercostal nerves, which creates an impression along the edge of the rib. Question 5. What types of violations of bronchial patency exist, what are they and what is reflected in X-ray examination?
Answer. There are three types of bronchial obstruction: partial, valvular and complete.
Partial obstruction consists in the narrowing of the bronchus, due to which an insufficient amount of air enters the alveoli, which are ventilated by this bronchus, while the alveoli partially collapse, the volume of the corresponding section of the lung decreases, and its density increases. Radiological manifestations:
Hypoventilation of the lungs;
Darkness of low or medium intensity;
Shift of interlobar fissures towards darkening;
During inspiration, the mediastinum shifts to the painful side.
Valvular obstruction occurs when the bronchus is narrowed, but slightly, while during inhalation, the bronchus expands, and air enters the alveoli in sufficient quantities, and when exhaled, due to the narrowing of the bronchus, the air does not completely escape, the alveoli overflow with air and occurs obstructive emphysema. X-ray manifestations of valvular obstruction.
Increased transparency of the lung field in the area of impaired ventilation.
Depletion of the pulmonary pattern.
An increase in the volume of a section of the lung, as evidenced by:
Displacement of interlobar fissures in the opposite direction;
Bulging of lung tissue through the intercostal spaces;
Horizontal arrangement of ribs;
Shift of the mediastinum to the opposite side.
Complete obstruction The bronchus leads to a decrease in the volume of the corresponding section of the lung due to collapse, since air does not enter the alveoli. It is called atelectasis and upon x-ray examination has the following manifestations:
Intense uniform darkening;
Displacement of interlobar fissures towards the lesion;
Shift of the mediastinum towards darkening.
Question 6. What are the main pathological radiological syndromes detected during examination of the chest organs, and what diseases do they occur in?
Answer. The main pathological radiological syndromes identified during examination of the chest organs and the diseases in which they occur are as follows.
Extensive blackout(due to compaction of lung tissue or lung field):
Atelectasis of the entire lung (the mediastinum shifts towards the lesion);
Condition after pneumonectomy, when fibrothorax is observed (the mediastinum shifts to the painful side);
Inflammatory infiltration - pneumonia (mediastinal organs are not displaced or slightly displaced in the opposite direction);
Tuberculosis (with bilateral damage, the mediastinum is shifted towards more massive changes): infiltrative, fibrous-cavernous, hematogenously disseminated, caseous pneumonia;
Pulmonary edema (mediastinum not displaced);
Hydrothorax, when fluid fills the entire pleural cavity (the mediastinum shifts to the opposite side).
Limited dimming with lobar lesions (the mediastinum is shifted to one side or another depending on the nature of the changes):
Lobar or segmental atelectasis;
Lobar or segmental pneumonia;
Tuberculosis infiltrate;
Pulmonary infarction;
Diaphragmatic hernia with access to the chest cavity of the abdominal organs through a defect in the diaphragm (the mediastinum is displaced in the opposite direction);
Partial effusion in the pleura (with a small amount of it, the mediastinum is not displaced, with a larger amount it is displaced in the opposite direction);
Calcification of the pleura is more common with tuberculosis (the mediastinum is not displaced).
Round shadow syndrome(mediastinum not displaced):
Nodular pneumonia;
Echinococcal unopened cyst (single or multiple shadows);
Tuberculoma (single or multiple shadows);
Benign tumor (single shadow);
Peripheral cancer (single shadow);
Metastases (single or multiple shadows).
Ring shadow syndrome form various cavities in the lungs or in volumetric formations during their decay (tumors) or opening (cysts), more often the mediastinum is not displaced:
Air cyst (single ring-shaped shadow);
Polycystic lung disease (multiple ring-shaped shadows);
Emphysematous bullae (multiple ring-shaped shadows);
Echinococcal cyst in the opening phase (single or multiple annular shadows);
Cavernous pulmonary tuberculosis (single or multiple annular shadows);
Abscess in the opening phase (single or multiple ring-shaped shadows);
Peripheral cancer with decay (single ring-shaped shadow).
Enlightenment syndrome lung field is manifested by an increase in its transparency due to the appearance of air in the pleura or its increase in the alveoli:
Bloating of the lungs (emphysema);
Pneumothorax (with varying degrees of collapse of the lung towards the root);
It can be like a condition after a pneumonectomy.
Dissemination syndrome visualized in the form of widespread bilateral focal (up to 1 cm) shadows. It could be:
Hematogenous disseminated tuberculosis;
Focal acute pneumonia (bronchopneumonia);
Pulmonary edema;
Multiple metastases;
Occupational diseases (silicosis, sarcoidosis).
Syndrome of pathological changes in pulmonary pattern observed in many diseases:
Acute and chronic pneumonia;
Poor circulation in the small circle;
Peribronchial cancer;
Interstitial metastases;
Tuberculosis;
Occupational diseases, etc.
There are three main options for changing the pulmonary pattern.
- Gain lung pattern - an increase in the number of linear shadows per unit area, for example, with inflammatory or tumor interstitial infiltration.
- Deformation lung pattern - a change in the location (direction) and shape (shortening, expansion) of the pattern elements. This happens, for example, with bronchiectasis (convergence, shortening and expansion of the bronchi).
- Weakening pulmonary pattern is observed less frequently, and a decrease in the number of linear shadows per unit area is noted, for example with emphysema.
The syndrome of pathological changes in the roots of the lungs occurs in two variants.
- Root expansion, what could be related:
With stagnation of blood in large vessels;
With the enlargement of the pulmonary lymph nodes, in this case round shadows appear in the root, and the outer border of the root becomes wavy or polycyclic.
- Lack of root structure when individual elements of the root are not differentiated, which is associated with infiltration of fiber or its fibrosis (for example, of an inflammatory nature).
Question 7. What are the causes of emergency conditions of the lungs and diaphragm, what diseases are related to them, how do they manifest themselves and how necessary is an X-ray examination?
Answer. Lung and diaphragm emergencies are associated with:
With closed or open chest injury;
With spontaneous opening of the lung cavity (cyst, bulla, etc.) into the pleura.
X-ray examination is carried out immediately in the X-ray room, intensive care unit, operating room and other place, since without this method it is impossible to clarify the nature of the damage.
Urgent diseases include conditions that require immediate treatment.
Foreign bodies X-ray examination determines their parameters:
Character (metal, contrasting glass, etc.);
Quantities;
Localizations;
Sizes;
Conditions of surrounding tissues.
Fractures ribs, collarbones, sternum, vertebrae. X-ray examination determines:
Their localization
Fracture line direction
Displacement of fragments,
Presence of hematoma, etc.
Pneumothorax(air in the pleura) appears:
In case of lung damage in cases of closed injury;
In case of an open injury with damage to the pleura (for example, a broken rib);
With spontaneous opening of the lung cavity into the pleura. Radiological signs of pneumothorax:
Air in the pleura in the form of parietal enlightenment of one or another width, against which there is no pulmonary pattern;
The collapse of the corresponding lung completely or partially, towards the root (it looks like a blackout of low intensity, against which an enhanced pulmonary pattern is visible);
Shift of the mediastinum to the opposite side.
Hydropneumothorax has the same causes and radiographic manifestations as pneumothorax, but in addition to air, there is liquid (blood or others) in the pleural cavity. Radiologically, in addition to the general signs with pneumothorax, additional ones appear:
Darkening of high intensity and homogeneous structure, the lower border of which merges with the diaphragm, and the upper border, in a vertical position, forms a horizontal level, which, depending on the amount of fluid, is determined by the level of any rib or fills the entire pleural cavity;
The mediastinum is sharply shifted to the opposite side.
Hemothorax appears when the pleura is damaged, then blood or fluid accumulates in it and there is no air, therefore, radiographically, in a vertical position, not a horizontal, but an oblique level of fluid is formed, which in a horizontal position spreads and creates a diffuse darkening of the pulmonary field, as with exudative pleurisy, the mediastinum shifts to the opposite side.
Emphysema of the soft tissues of the chest occurs when gas originating from the pleural space is distributed among the muscle fibers, creating a so-called “feathery” pattern on x-ray.
Mediastinal emphysema is associated with the penetration of air through the interstitial space of the lung into the mediastinal tissue, then a strip of air appears on the radiograph, delimiting the mediastinum in the form of a light “edge”.
Hemorrhage in the pulmonary parenchyma during x-ray examination it appears in the form of areas of darkening, varying in intensity, size and shape.
Diaphragm injury. X-ray signs.
High location.
Limitation of mobility.
The appearance of fluid in the pleural sinuses of the corresponding side.
Discontinuity of the diaphragm dome contour.
Penetration of the abdominal organs into the chest through a defect in the diaphragm, then note:
Uneven darkening of the corresponding pulmonary field;
In an upright position, one or more pathological levels are visible due to air and fluid in the prolapsed stomach or intestines;
When taking barium sulfate per os or with a contrast enema, the contrasted stomach or intestines can be seen in the chest cavity.
Question 8. What are the essence and radiological manifestations of polycystic disease?
Answer. Polycystic- a congenital disease associated with underdevelopment of lung tissue, usually within a lobe or segment. In this case, the lung tissue is replaced by multiple air cysts, and the volume of the corresponding part of the lung is reduced.
X-ray manifestations of polycystic disease:
Multiple ring-shaped shadows with thin uniform walls, which creates the symptom of “soap bubbles”;
Horizontal levels of liquid appear at the bottom of the cavities if an inflammatory process occurs against this background;
The interlobar fissures are shifted towards the lesion, which indicates a decrease in the volume of the lesion;
For the same reason, the shadow of the mediastinum is also shifted towards pathological changes;
Tomograms and bronchograms show that the bronchi are deformed due to their underdevelopment; anatomically fully formed bronchi are not identified in the zone of changes.
Question 9. There are two main forms of acute bacterial (pneumococcal) pneumonia, depending on the volume and nature of the damage to the lung parenchyma. What are these forms, what are their x-ray semiotics and what is the time for an x-ray examination to diagnose these conditions?
Answer. Depending on the volume and nature of the lesion in the lung parenchyma, the following are distinguished: forms of acute bacterial (pneumococcal) pneumonia:
Parenchymal pneumonia occupies part of a segment, a segment, a share, or even the entire lung.
Pathoanatomically hyperemia occurs, the liquid part of the blood sweats into the alveoli, causing their airiness to become less.
X-ray semiotics:
Darkening of the corresponding area of the lung;
The volume of lung damage increases slightly, as evidenced by the displacement of the interlobar fissures, and sometimes by the displacement of the mediastinum in the opposite direction;
Darkening, if it is limited to the pleura (segmental or lobar), has clear contours, and subsegmental darkening has unclear contours;
The darkening intensity is average, increasing towards the periphery;
Heterogeneous structure, against the background of darkening, light stripes of unchanged bronchi are visible;
The root on the affected side is expanded and unstructured (“smeared”) due to inflammatory infiltration;
At the root, lymph nodes enlarged due to hyperplasia are visible in the form of round shadows;
An oblique level of fluid may appear in the pleura, usually extending slightly beyond the external costophrenic sinus (if complicated by exudative pleurisy).
Lobular pneumonia (bronchopneumonia) differs from parenchymal in that individual lobules of the lung are affected. Radiological symptoms:
Multiple focal or round shadows, averaging 1-1.5 cm in size, which corresponds to the size of the lobules;
Medium intensity dimming;
The structure is heterogeneous;
The outlines are unclear;
Shadows can merge.
Difficulties arise in the differential diagnosis of tuberculosis; the distinctive features are the following:
The number of foci in tuberculosis increases towards the apex of the lung, and in pneumonia - towards the diaphragm (the apexes are not affected);
During dynamic observation, foci disappear after 12 months for tuberculosis, and after 2 weeks for pneumonia.
Time of X-ray examination When diagnosing pneumonia, it consists of the following stages.
At the initial visit to the doctor, but if clinically there is pneumonia, and it is not detected x-ray, then a repeat examination is required 2-3 days after the onset of the disease, since on the first day there is no infiltration in the lungs (no darkening), but there is only hyperemia (increased pulmonary pattern due to the vascular component), which is often overlooked.
Study after 2 weeks for dynamic control and resolving the issue of the nature of the disease:
If acute the course of the disease, the infiltrate disappears;
If subacute- the infiltrate does not disappear, but fragments, its intensity and heterogeneity increase;
If complicated course, then abscess formation, pleurisy, etc. appear.
If after 2 weeks there is no change in the infiltrate (darkening) in the direction of its reduction, then this serves as an indication for tomography,
which will allow us to establish the primary or secondary nature of the inflammatory changes.
A study after 1 month is carried out in case of subacute or protracted course of the disease. By this time, the infiltrate (darkening) should disappear; if not, then tomography is repeated, and, if necessary, bronchography and CT.
After 2 months, an X-ray examination is carried out if the course is prolonged, and if the infiltrate does not disappear after 1 month, then the transition of the disease to a chronic course or secondary process can be suspected; tomograms, bronchograms, and CT scans can be prescribed for clarification.
Question 10. As a result of what pathological process in the lungs are formed bronchiectasis, what is the volume of the affected area of the lung, radiological signs and the most rational algorithm for using radiological techniques to identify these changes in the bronchi and lung parenchyma?
Answer.Bronchiectasis are formed as a result of the development of connective and fibrous tissue in the pulmonary parenchyma as a result of repeated acute pneumonia, i.e. chronic inflammation. The corresponding area of the lung lesion decreases in volume due to fibroatelectasis.
X-ray signs.
The darkening is intense.
The structure of the darkening is heterogeneous, the volume of the darkening area is reduced, as evidenced by the displacement of the interlobar fissures and mediastinum towards fibroatelectasis.
The bronchi on tomograms and bronchograms are brought together, shortened, deformed in the form of a “beaded cord”, which reflects the picture of deforming bronchitis, then they expand more and more and bronchiectasis of two types occurs:
Cylindrical (expansion along the length of the bronchi);
Saccular (extensions at the ends of the bronchi).
The root is usually fibrotic, i.e. compacted and its structural units are clearly visible.
Deformation of the bronchi is also noted in adjacent segments. Rational algorithm X-ray techniques for identifying bronchiectasis.
First they do plain radiographs in direct and corresponding lateral projections, they reveal darkening of the lobe or
segment with a decrease in their size and other above-mentioned signs of atelectasis.
Direct superexposed radiograph(using rays of increased rigidity) allows you to determine the structure of the darkening and, possibly, see the lumen of the bronchi.
Tomograms in frontal and lateral projections are more informative for visualizing the lumen of the bronchi, and the presence of bronchiectasis can be suspected.
Bronchography(introduction of contrast into the lumen of the bronchi) in two projections makes it possible to most accurately determine the presence, nature and prevalence of bronchiectasis.
CT carried out after bronchography or instead of it in doubtful cases to definitively establish the nature and extent of the pathological process.
Question 11. What is a lung abscess, what are its radiological signs, what do they depend on?
Answer.Lung abscess- a limited focus of purulent inflammation, pathoanatomically represents a cavity filled with purulent fluid. X-ray signs of an abscess depend on what phase it is in: unopened, opened, or reverse development after anti-inflammatory therapy.
X-ray signs unopened abscess:
Symptom of “round shadow”;
Shadow dimensions 3-8 cm;
The contours of the shadow are unclear;
Intensity is medium;
The structure is homogeneous;
In the root on the affected side, enlarged lymph nodes are visible due to hyperplasia; the root is unstructured due to infiltration of fiber.
X-ray signs opened abscess:
Symptom of “ring-shaped shadow”;
The decay cavity in the form of a centrally located enlightenment;
The walls of the cavity are thick, uneven due to parietal shadows ("sequesters");
Inside the cavity at the top there is air in the form of clearing, since the opening of the abscess most often occurs in the bronchus, and at the bottom
(at the bottom of the cavity) - the horizontal level of the liquid in the form of blackout;
External and internal contours of the cavity wall are fuzzy;
During bronchography, contrast material enters the abscess cavity, the surrounding bronchi are deformed to the point of bronchiectasis;
Hyperplastic lymph nodes are visible in the root; the structure of the root is not determined due to infiltration.
X-ray signs of an abscess in the phase of reverse development after anti-inflammatory therapy:
In acute cases, after 2 weeks the size of the shadow decreases, the wall of the cavity becomes thinner, and the amount of fluid decreases;
After 3-4 weeks - complete disappearance of the cavity and normalization of the root;
With a protracted and chronic course, the process is delayed, over 4-8 weeks.
Question 12. Which of the domestic radiologists made a significant contribution to the description of the X-ray picture of pulmonary echinococcus, how does infection occur, the formation of an echinococcal cyst and its complications? What are the phases of cyst development and x-ray semiotics in each of these phases during conventional x-ray examination?
Answer. A significant contribution to world knowledge about the X-ray picture of pulmonary echinococcus was made by N.E. Stern and V.N. Stern - Doctor of Medical Sciences, Head of the Department of Radiology at Saratov Medical University in the period 1935-1952, respectively. and 1952-1972 V.N. Stern wrote a monograph on echinococcosis, which is known both in our country and abroad.
compresses these vessels and bronchi, causing its own death and becoming saturated with lime salts. Complications of the cyst:
In the pleura with the formation of hydropneumothorax (rarely),
In the bronchus (often) with secondary seeding,
Into the lungs (bronchogenic contamination),
In vessels with hematogenous seeding in the liver, bones, kidneys, etc.;
The X-ray picture shows two phases of development of echinococcal cyst of the lungs, which, during a routine x-ray examination, are manifested by the following signs.
The phase of an unopened cyst, completely filled with fluid. X-ray semiotics:
Symptom of a “round shadow”, which is actually always oval;
The shape of the shadow changes with deep breathing, which indicates liquid content;
Single or multiple (2-3), in the latter case unilateral or bilateral lesions;
The contours are clear, smooth or uneven due to diverticulum-like protrusions and notches;
Sizes from 1 to 20 cm;
The structure is homogeneous;
Intensity is medium;
A rim of enlightenment is defined around the shadow by pushing aside the surrounding tissues;
The growth of the cyst is slow, but spasmodic.
With a small amount of air in the pericystic fissure, cyst rupture, while along the periphery of the shadow of the cyst
(between the fibrous capsule and the chitinous membrane) bubbles or stripes of clearing (air) are detected. The tear does not manifest itself clinically and the only diagnostic method is x-ray. Before the next stage - rupture of the cyst - an operation (removal of the cyst) is necessary to prevent contamination.
As air accumulates further in the pericystic fissure, a symptom occurs "crescent enlightenment" at the superior pole of the cyst. This is already a sign cyst rupture. Then a cough suddenly appears with the release of a large amount of liquid sputum and pain in the side. In this phase, differential diagnosis is carried out with tuberculoma in the decay phase, but in the latter case, the crescent-shaped clearing will be associated with the mouth of the draining bronchus (in the lower pole of the shadow), there will also be a path to the root and foci of screening in the surrounding tissue.
Then, with even greater accumulation of air in the pericystic fissure, the so-called symptom is visualized "double arch" which is created: on top - a fibrous capsule, below - a chitinous shell in the form of a dome (due to negative pressure in the cyst), partially air enters the cyst cavity.
At the last stage, a symptom occurs "hydropneumocysts" when there is air in the cyst (above) and a horizontal level of liquid (below), above which an irregularly shaped shadow is visible due to the floating wrinkled chitinous membrane (symptom of “floating lily”), which moves when the body position changes (symptom of "kaleidoscope").
Question 13. What are the tomographic and bronchographic signs of an hydatid cyst and in what phase of development can they be identified?
Answer.Tomographic and bronchographic signs echinococcal cyst.
Symptom of “grasping hand” due to the pushing and spreading of the bronchi by the cyst is detected in any phase of cyst development, although it has the greatest differential diagnostic value with an unopened cyst.
They are diagnosed both in the phase of unopened and in the phase of opened cyst.
Flow of contrast from the bronchi into the pericystic fissure with bronchography in the phase of an unopened cyst - a pathognomonic sign of echinococcus.
Admission through the bronchi into the cyst cavity contrast during bronchography in the phase of the opened cyst, while against the background of a high-contrast substance in the cavity it is often visible wrinkled chitinous shell in the form of irregularly shaped filling defects.
Question 14. What is a hamartoma? What are its radiological signs?
Answer.Hamartoma - a benign tumor that is most often seen in the lungs.
Radiological signs of hamartoma:
Symptom of “round shadow”;
The shape of the shadow is round, oval or pear-shaped;
Dimensions up to 5 cm;
The contours are clear, even;
Large blocks of lime are visible against the background of the shadow (in the center);
There is no decay in a tumor;
There is a rim of enlightenment around the shadow due to pushing aside neighboring tissues;
The bronchi are not changed;
Growth is slow.
Question 15. What elements of the lungs does central cancer come from? What types of central cancer differ depending on the direction of tumor growth in relation to the bronchus wall, what x-ray symptoms do they manifest?
Answer.Central cancer comes from the large bronchi:
Main;
Equity;
Segmental.
Types of central cancer depending on the direction of its growth in relation to the wall of the bronchus.
Exobronchial cancer grows outward from the wall of the bronchus, so its main x-ray symptom is a tumor node in the region of the corresponding root, consisting of large bronchi:
Hemispherical shading;
The outer contour is uneven, indistinct, radiant;
The inner contour of the shadow is adjacent and merges with the mediastinum;
On tomograms and bronchograms, it is clear that the bronchi passing through the shadow are not initially changed.
Endobronchial cancer grows into the lumen of the bronchus quite quickly, therefore, in most cases, it manifests itself as a symptom of complete obstruction of the bronchus with the development of atelectasis. On radiographs:
Atelectasis is seen as a high-intensity darkening of the entire lung, lobe, or segment;
Its structure is homogeneous;
The interlobar fissures and mediastinum are shifted towards the lesion due to a decrease in the volume of the corresponding part of the lung;
Tomograms and bronchograms show a bronchial stump due to its obstruction by a tumor.
Peribronchial or branched cancer spreads along the wall of the bronchus. X-ray determined:
The main pathological symptom on plain radiographs is a diffuse enhancement of the pulmonary pattern with a fan-shaped extension of linear shadows from the root into the lung tissue;
Thickening of the walls of the bronchi over a large area, which is visible on tomograms;
Often combined with exobronchial cancer.
Question 16. What anatomical structures of the lungs does peripheral cancer come from and how does it manifest radiographically? Answer.Peripheral cancer comes from the small bronchi. X-ray symptoms peripheral cancer.
Symptom of "round shadow".
The sizes depend on the time of detection and range from 0.5 cm to 4-5 cm or more.
The shape of the shadow is irregularly rounded, star-shaped, amoeboid or dumbbell-shaped.
The contours are uneven, lumpy, indistinct, and are characterized by their radiance.
The intensity of the shadow is weak, increasing with increasing size.
The structure is heterogeneous, which may be due to the following reasons.
Multinodularity due to the growth of the tumor from several centers; as a result, the tumor consists of several merging round shadows.
Decay, which happens often, then the shadow becomes ring-shaped, and a decay cavity appears, its characteristics:
The location is eccentric, less often - central;
The shape is wrong;
The walls of the cavity are uneven and thick;
There is no liquid in the cavity or its amount is small;
The internal contour of the wall is clear;
There may be partitions in the cavity.
Finely lumpy calcification (rare).
The interlobar fissure adjacent to the tumor is either retracted or bulging.
Question 17. How can lung cancer be complicated, regardless of its growth pattern?
Answer. Lung cancer, regardless of its growth pattern, may have the following complications.
Impairment of bronchial obstruction of varying degrees due to compression or germination of the main, lobar or segmental bronchi with the formation of pulmonary phenomena:
Hypoventilation (with incomplete obstruction of the bronchus);
Atelectasis (with complete obstruction).
Disintegration in the tumor (eccentric or central in the cavitary form of peripheral cancer).
Pneumonia, which is called paracancrosis or pneumonitis.
Pleurisy, the causes of which may be:
Compression of lymphatic vessels;
Blocked lymph nodes;
Metastases in the pleura.
Metastases to the lymph nodes of the root.
Metastases to the lymph nodes of the mediastinum.
Tumor invasion of neighboring organs and tissues:
Mediastinum;
chest wall.
Distant metastases most often:
To the liver;
In the brain;
In the bones.
Question 18. To which organs and tissues does lung cancer metastasize and what radiological symptoms does it manifest?
Answer. Lung cancer metastasizes to the following organs and tissues, manifesting itself radiographically with the symptoms described below.
IN lymph nodes of the roots:
Root growth;
The appearance of round shadows in the corresponding root;
There is no loss of root structure, since there is no infiltration.
IN mediastinal lymph nodes:
Expansion of the mediastinum shadow mainly in its upper and middle sections;
Waviness and polycyclicity of the outer contour of the mediastinum;
An increase in the bifurcation angle of the trachea, as seen on tomograms.
IN lung tissue:
Single or multiple round shadows;
The contours of the shadows are clear and even;
The structure is homogeneous;
The shadows don't merge;
The number of shadows increases towards the aperture;
Shadows do not disappear after anti-inflammatory therapy.
IN ribs, in this case, germination is possible rather than metastasis, which happens mainly with peripheral cancer. On a radiograph, this is manifested by the absence of part of the rib both in cases of metastasis and in cases of germination.
IN pleura with pleurisy, which can be:
Metastatic as a result of contamination of the pleura;
Reactive.
The X-ray picture does not differ from pleurisy of any other etiology:
Fluid in the pleura in the form of darkening;
The upper level of fluid is oblique, located within the sinus (costophrenic) and above, up to a total darkening of the entire pulmonary field, which depends on the amount of fluid;
The lower limit of darkening always merges with the aperture;
The darkening has a uniform structure;
The darkening intensity is high;
The mediastinum shifts to one degree or another in the opposite direction.
Question 19. What is the algorithm for radiological methods aimed at identifying lung cancer, clarifying the nature of its growth and prevalence? What is the need to use each method?
Answer. The algorithm of radiological methods aimed at detecting lung cancer, clarifying the nature of its growth and prevalence seems to be as follows.
To detect lung cancer in the early stages it is necessary fluorography, which is carried out annually, starting from the age of 15, special attention is paid to high-risk groups, where the following factors are important:
Heredity;
Smoking;
Repeated unilateral pneumonia;
Hemoptysis, etc.
After identifying signs on fluorograms that are suspicious of lung cancer, it is necessary to plain radiographs in frontal and lateral projections, which allow us to identify:
Hypoventilation or atelectasis;
Shadow in the root or parenchyma of the lung;
Expansion of roots and mediastinum;
Destruction of ribs, etc.
X-ray.
Clarification of tumor localization thanks to polypositional study.
Identifying functional symptoms.
Detection of liquid in cavities (by its movement).
Determination of the mobility of the diaphragm (its immobility is noted during compression or germination of the phrenic nerve).
Carrying out differential diagnosis:
With vascular formations that pulsate;
With liquid formations that change their shape when breathing.
Tomography allows you to specify the following parameters.
Dimming options:
Outlines;
Structures, including identifying and establishing the nature of decay.
Condition of surrounding tissues.
Metastasis to the lymph nodes of the root and mediastinum.
Condition of the bronchi:
Bronchial stump with endobronchial cancer;
Bronchial narrowing in exobronchial and peripheral cancer;
Multiple narrowings in peribronchial cancer.
Increase in the bifurcation angle of the trachea.
Bronchography produced after tomography, when it was not possible to see the lumen of the bronchi, while identifying or clarifying the above changes in the bronchi.
CT carried out after the previous methods, if there are doubts about the nature and prevalence of the pathological process.
Determine the presence of cancer.
Differential diagnosis is carried out with liquid volumetric formations by density using the Hounsfield scale:
With an abscess;
With cysts;
The direction of tumor growth is determined.
Metastasis to the lymph nodes of the root and mediastinum is detected.
The growth of the ribs and pleura is determined.
Distant metastases are detected (to the liver, brain, etc.).
Question 20. Tumors of what localizations are most common? metastasize to the lungs What metastases of the chest cavity can they be combined with and how are they manifested radiographically?
Answer. Most often, tumors from the following locations metastasize to the lungs:
Mammary gland;
Stomach;
Intestines;
Prostate gland, etc.
Metastases in the lungs can be combined with other metastases of the chest cavity:
To the lymph nodes of the root;
In the lymph nodes of the mediastinum;
In the ribs;
Into the vertebrae.
X-ray manifestations of metastases in the lungs.
Miliary metastases(multiple, bilateral), radiographically they look like:
In the form of focal shadows;
The contours are clear and even;
The lesions do not merge;
The number of shadows increases towards the diaphragm, and the apexes of the lungs are not affected (unlike tuberculosis);
Metastases in the form of round shadows:
Single or multiple;
Single-sided or double-sided;
Shadow sizes up to 1-2 cm;
The contours are clear and even;
The structure is homogeneous;
Interstitial metastases(spread along the bronchi).
Diffuse enhancement of the pulmonary pattern;
Thickening of the walls of the bronchi (on tomograms).
The same signs are noted in primary peribronchial cancer, but clinical information helps in the diagnosis of metastases:
History of cancer surgery;
Presence of a primary tumor, etc.
SITUATIONAL TASKS
Task 1. In patient D., 44 years old, fluorography revealed a symptom of a round shadow.
What should be the algorithm of methods and techniques of radiation research to establish the nature of this shadow?
Task 2. X-rays and tomograms of the chest organs of patient T., 67 years old, reveal multiple bilateral round shadows, the number of which increases towards the diaphragm, their contours are smooth, their diameter is up to 1 cm, they do not merge, the structure is homogeneous. The roots on both sides are expanded due to enlarged lymph nodes, structural, polycyclic.
Conclusion: pulmonary tuberculosis.
Do you agree with this conclusion, on what basis do you confirm or refute it?
Task 3. X-rays and tomograms of the chest organs of patient Z., 48 years old, revealed atelectasis of the middle lobe in the form of darkening of a heterogeneous structure. In the adjacent segments, an enhanced and deformed pulmonary pattern is visible. On the bronchograms on the right, the bronchi of the S IV-V segments are visible, contrasted throughout their entire length; they are brought together, shortened, and have the appearance of a “beaded cord”.
What should be the conclusion based on the above picture?
Task 4. X-rays of the chest organs of patient Zh., 25 years old, reveal pathological symptoms that raise suspicion of enlarged mediastinal lymph nodes.
Suggest techniques and methods of radiation diagnostics that would clarify the above suspicion.
Task 5. On radiographs of the chest organs of patient L., 44 years old, a total darkening is determined on the right, which has a high intensity, homogeneous structure, the mediastinal shadow is shifted to the left.
What do you think causes the picture described?
Task 6. In patient A., 24 years old, an X-ray examination of the chest organs revealed fluid in the left pleural cavity in the form of a high-intensity homogeneous darkening, the lower contour of which merges with the diaphragm, the mediastinum is shifted to the opposite side.
In what cases will the upper boundary of the liquid have an oblique level, and in what cases will it have a horizontal level?
Task 7. X-ray of the chest organs of patient D., 36 years old, on the right reveals a shadow of a round shape, medium intensity, heterogeneous structure, up to 2 cm in diameter, its contours are clear, but uneven. There is a connection between the shadow and the tail part of the root. A suspicion arises about the vascular nature of this formation (angioma).
Prescribe an x-ray examination technique that will help give the correct conclusion based on the additional symptoms obtained (which ones?).
Task 8. On radiographs of the chest organs in frontal and lateral projections of patient U., 69 years old, a pathological shadow of a hemispherical shape with an outer uneven radiant contour is determined in the right root. Additional tomograms show that the bronchi passing through the shadow are not changed.
What causes the shadow at the root: central exobronchial cancer or enlarged lymph nodes?
Task 9. During the initial X-ray examination of patient D., 57 years old, a “round shadow” symptom is detected in the left lung in S VI, with a diameter of up to 5 cm, the contours are unclear. The impression is of peripheral cancer complicated by paracancrosis pneumonia, as there are clinical signs of inflammation (fever, cough, leukocytosis). After anti-inflammatory therapy, 1 week later, during control radiography, the round shadow turned into a ring-shaped one, i.e. disintegration has occurred in the form of a clearing cavity, which has a central location, the walls of the cavity are uneven, unclear, the cavity contains a large amount of liquid, and on tomograms the tuberosity of the contours and partitions in the cavity is not determined.
Has the nature of the decay changed your initial impression of the pathological process?
Problem 10. Patient M., 43 years old, who came from a village where he has his own farm (dogs, chickens, a cow, etc.), had radiographs of the chest organs taken in two projections due to low-grade fever and cough. On the right, in S VIII, a ring-shaped shadow of an oval shape was found, measuring 3x4.5 cm, the contours are clear, even, the wall of the cavity is thin, uniform, contains a horizontal level of liquid, under which an additional shadow of irregular shape is determined, moving when the position of the body changes.
Conclusion: opened abscess.
Do you agree with the conclusion?
ABSTRACT TOPICS FOR INDEPENDENT WORK,
NIRS AND UIRS
1. Types of anomalies in the development of the lungs and their radiological manifestations.
2. Features of X-ray diagnosis of acute pneumonia in children.
3. Shadow picture in various forms of acute pneumonia in adults, algorithm for using radiation methods and techniques and their informativeness in identifying pathological changes.
4. Features of the X-ray picture in various phases of development of an echinococcal cyst of the lung.
5. X-ray diagnosis of destructive pneumonia in children.
6. Some diagnostic aspects for X-ray detection of abscess and abscess pneumonia.
7. Computed tomography and x-ray tomography in the diagnosis of central lung cancer and its regional metastases.
8. Differential X-ray diagnosis of round shadows in the lungs.
9. X-ray manifestations of chronic pneumonia.
10. Radiation diagnostics in identifying and assessing the nature of intrabronchial and extrabronchial benign tumors.
11. Differential X-ray diagnosis of pulmonary disseminations.
12. Fluorography and tomography in the assessment of various forms of pulmonary tuberculosis.
13. Information content of radiation methods in the diagnosis of tumors and mediastinal cysts.
14. X-ray diagnosis of pleural diseases.
SCHEME FOR DESCRIPTION OF RADIOGRAMS AND RADIOSCOPPIES OF THE CHEST CAVITY ORGANS
I. Patient's name and age.
II. General assessment of the radiograph.
Methodology.
X-ray.
X-ray:
Survey radiograph;
Sight radiograph;
Overexposed radiograph.
Tomogram.
Bronchogram.
Computer tomogram.
Angiogram.
Indication of the organs being examined (organs of the chest cavity).
Projection of the study:
Lateral;
Lateroposition.
Image quality:
Contrast;
Sharpness;
Beam hardness;
Correct installation, etc.
III. Study of the lungs.
Determination of chest shape:
Regular;
In the form of a bell
Barrel-shaped, etc.
Lung volume assessment:
Not changed;
The lung or part of it is enlarged;
Reduced.
Establishment of the state of the lung fields:
Transparent;
Blackout;
Enlightenment.
Pulmonary pattern analysis:
Not changed;
Weakened;
Deformed.
Analysis of the roots of the lungs:
Structurality;
Location;
Enlarged lymph nodes;
Vessel diameter.
Respiratory movements of the ribs, diaphragm;
Change in lung pattern during breathing.
Identification and description of pathological syndromes:
Shadow picture:
Blackout;
Enlightenment.
Localization:
By shares;
By segment.
Dimensions in centimeters (at least two sizes are indicated).
Round;
Oval;
Incorrect;
Triangular, etc.
Outlines:
Smooth or uneven;
Clear or fuzzy.
Intensity:
Average;
High;
Lime density;
Metal density.
Shade structure:
Homogeneous;
Heterogeneous due to decay or lime inclusions, etc.
Functional signs by fluoroscopy:
Changes in the shape of a round shadow during breathing - with fluid formations (cysts);
Shadow pulsation in vascular formations (aneurysms, angiomas), etc.
Correlation of pathological changes with surrounding tissues:
Strengthening the pulmonary pattern in the surrounding tissues;
A rim of enlightenment around a round shadow due to pushing aside adjacent tissues;
Pushing or pushing apart bronchi or vessels, etc.
Dropout areas, etc.
IV. Study of mediastinal organs.
Location:
Not displaced;
Displaced (towards pathological changes in the lungs or in the opposite direction).
Dimensions:
Not enlarged;
Enlarged due to the left ventricle or other parts of the heart;
Expanded to the right or left in the upper, middle or lower sections.
Configuration:
Not changed;
If it is changed, it may be due to space-occupying formations of the heart, blood vessels, lymph nodes, etc.
Outlines:
Uneven.
Functional state during fluoroscopy:
Heart rate;
Jerky displacement of the mediastinum during exhalation towards atelectasis, etc.
V. Study of the walls of the chest cavity.
Condition of the pleural sinuses:
Free;
They have pleurodiaphragmatic adhesions.
Condition of soft tissues:
Not changed;
Enlarged;
There is subcutaneous emphysema;
Foreign bodies, etc.
Condition of the skeleton of the chest and shoulder girdle:
Location of bones;
Their shape;
Outlines;
Structure;
The presence of fused or non-united fractures.
Aperture condition:
The location is normal;
Proximal displacement by one intercostal space, etc.;
The domes have smooth contours or are deformed by pleurodiaphragmatic adhesions;
Mobility of the diaphragm during fluoroscopy.
VI. Conclusion about the condition of the chest organs.
In the absence of pathological changes, we can limit ourselves to a descriptive picture without a conclusion.
Overexposed radiographs;
Tomograms;
Bronchograms;
Angiograms;
VIII. Description of additional techniques and methods, confirmation or clarification of the previously described picture, description of newly identified pathological signs.
IX. Final conclusion about the nature of the disease, for example:
Pneumothorax;
Parenchymal pneumonia;
Central exobronchial cancer without metastases;
Peripheral cancer;
Echinococcus in the unopened phase or others.
An alternative option can be used in difficult to diagnose cases. It should be noted that when any pathological
gical syndrome in the lungs, pleura, mediastinum, chest, it is always described first, and then the condition of the surrounding tissues is described according to the above scheme.
SAMPLES OF PROTOCOLS DESCRIPTIONS OF SOME RADIOGRAMS OF THE CHEST CAVITY ORGANS
Protocol? 21
Patient Sh., 15 years old. X-ray of the chest organs in direct projection(Fig. 3.1).
The right lung is in a collapsed state (approximately 1/3 of its volume), the left lung is in an expanded state. On both sides there is a diffuse strengthening of the pulmonary pattern and its deformation is predominantly of the cellular type. The roots of the lungs are fibrotic. The sinuses of the pleura are free. The mediastinal shadow is shifted to the left, not expanded. The diaphragm is located at the level of the VI rib, its shape is domed.
Conclusion: right-sided pneumothorax, apparently due to rupture of the alveoli due to fibrosing alveolitis.
Rice. 3.1. Patient Sh., 15 years old. X-ray of the organs of the chest cavity in direct projection.
Right-sided pneumothorax, apparently due to alveolar rupture due to fibrosing alveolitis
Protocol? 22
Patient K., 30 years old (Fig. 3.2).
(Fig. 3.2 a) and right lateral projections(Fig. 3.2 b).
The lower right lobe is darkened, of normal volume. Darkening of medium intensity, which increases towards the periphery, heterogeneous
Rice. 3.2. Patient K., 30 years old. Right-sided lower lobe parenchymal pneumonia:
a - X-ray of the organs of the chest cavity in direct projection; b - X-ray of the organs of the chest cavity in the right lateral projection. The disappearance of pathological changes after 10 days, which indicates a favorable, acute course of right-sided lower lobe parenchymal pneumonia: c - x-ray of the chest cavity in a direct projection; d - radiograph of the organs of the chest cavity in the right lateral projection
structure; against its background, light stripes of the bronchi are visible (in the medial sections). The right root is expanded, not structured. In other sections on the right and left, the pulmonary fields are transparent, the pulmonary pattern is not changed, the left root is not expanded, it is structural. The mediastinal shadow is not displaced or expanded, the aorta has a normal location and diameter. Sinuses of the pleura are free. The diaphragm is located at the level of the VI rib, its shape is dome-shaped.
Conclusion: right lower lobe parenchymal pneumonia.
X-rays of the chest organs in the straight line(Fig. 3.2 c) and right lateral projection(Fig. 3.2 d) after 10 days.
The previously described darkening is not detected. Lung fields are transparent. The pulmonary pattern is not changed. The roots of the lungs are not expanded, structural. Mediastinal shadow of usual location, size and configuration. Sinuses of the pleura are free. The diaphragm, bone frame and soft tissues are not changed.
Conclusion: the disappearance of the above-described changes after 10 days indicates a favorable acute course of right-sided lower lobe parenchymal pneumonia.
Protocol? 23
Patient D., 58 years old (Fig. 3.3).
X-rays of the chest organs in the straight line(Fig. 3.3 a), right(Fig. 3.3 b) and left side(Fig. 3.3 c) projections.
On both sides, more on the left, mainly in S IV-V, darkening of medium intensity, heterogeneous structure is found, against its background light stripes of the bronchi are visible, the volume of the affected segments is not changed. Both roots are enlarged, nonstructural, and enlarged lymph nodes are visible in them. In other sections on the right and left, the pulmonary fields are transparent, the pulmonary pattern is not changed. The mediastinal shadow is not displaced, slightly expanded due to the left ventricle of the heart, the aorta has the usual location and diameter, and is compacted. The sinuses of the pleura are free. The diaphragm is located at the level of the VI rib, its shape is dome-shaped.
Conclusion: bilateral parenchymal pneumonia mainly in the lingular segments, age-related changes in the heart and aorta.
Radiographs of the chest organs in direct, right and left lateral projections after 10 days.
Rice. 3.3. Patient D., 58 years old. Bilateral parenchymal pneumonia, mainly in the lingular segments, age-related changes in the heart and aorta:
a - radiograph of the chest organs in a direct projection; b - radiograph of the chest organs in the right lateral projection; c - radiograph of the chest organs in the left lateral projection. Spiral computed tomography after 10 days (d) - confirmation of the x-ray report, no evidence of the presence of a malignant pathological process was received
X-ray picture of the above-described changes without dynamic shifts. To exclude the malignant nature of the pathological process, spiral computed tomography is recommended.
Spiral computed tomography(Fig. 3.3 d).
The detected changes are fully consistent with the x-ray data. On both sides, more on the left, in S IV-V, infiltrative changes of medium density, heterogeneous structure are detected, against their background unchanged lumens of the bronchi are visible, the volume of the affected segments is not changed. Both roots are enlarged, nonstructural, and enlarged lymph nodes are visible in them. In other sections on the right and left, no pathological changes in the lungs are visualized. The mediastinal shadow is not displaced, slightly expanded due to the left ventricle of the heart, the aorta has the usual location and diameter, and is compacted. No fluid is detected in the pleural cavity. The diaphragm is located at the level of the VI rib, its shape is dome-shaped.
Conclusion: bilateral parenchymal pneumonia mainly in the lingular segments, transition to a protracted course. Age-related changes in the heart and aorta. No data were obtained regarding the malignant nature of the pathological process.
Protocol? 24
Patient B., 66 years old (Fig. 3.4).
X-rays of the chest organs in the straight line(Fig. 3.4 a) and left side(Fig. 3.4 b) projections.
On the left, in the basal segments of the lower lobe, a weakly intense darkening is noted, against which an intensified, contiguous and deformed pulmonary pattern of uneven diameter is visualized. Throughout the rest of the left, as well as in the right lung, the pulmonary fields are transparent, the pulmonary pattern is not changed. The roots are not expanded, structural. The mediastinal shadow is shifted to the left. Sinuses of the pleura are free. The diaphragm is located at the level of the VI rib, its shape is not changed.
Conclusion: atelectasis S VII-IX-X on the left; to clarify its nature, X-ray tomography in direct and left lateral projections is recommended.
X-ray tomograms in frontal and left lateral projections.
On tomograms, the darkening of S VII-IX-X on the left looks heterogeneous, the bronchial lumen is not visualized, therefore bronchography is necessary to resolve the issue of the presence of fibroatelectasis or obstructive atelectasis.
Rice. 3.4. Patient B., 66 years old. Atelectasis S VIII-IX-X on the left during radiography: a - radiograph of the chest organs in a direct projection; b - radiograph of the chest organs in the left lateral projection. Establishment of fibroatelectasis and mixed bronchiectasis in S VIII-IX-X with bronchography: c - bronchogram in direct projection; d - bronchogram in the left lateral projection
Straight bronchogram of the left lung(Fig. 3.4 c) and left side(Fig. 3.4 d) projections.
On the left, there is a convergence and shortening of the bronchi S VII-IX-X, their uneven expansion along their length and in the form of sacs at the ends
(cylindrical and saccular bronchiectasis), the rest of the bronchi are not changed.
Conclusion: fibroatelectasis of the lower lobe of the left lung, mixed bronchiectasis S VII-IX-X.
Protocol? 25
Patient F., 45 years old (Fig. 3.5).
X-rays of the chest organs in the straight line(Fig. 3.5 a) and right lateral projections.
On the right, the upper lobe is darkened and reduced in size. The darkening is intense, increasing towards the root, uniform. The left pulmonary field is transparent, the pulmonary pattern is normal. The right root is pulled up, its shadow merges with the darkening described above, the left root is not changed. The sinuses of the pleura are free. The mediastinal shadow is not displaced, of normal size and configuration. The diaphragm is located at the level of the VI rib, its shape is dome-shaped.
Conclusion: atelectasis of the upper lobe of the right lung, X-ray tomography in two projections is recommended to clarify the nature of atelectasis.
X-ray tomograms in a direct projection 9.5 cm from the back (Fig. 3.5 b) and in the right lateral projection 5 cm from the spinous processes (Fig. 3.5 c).
A stump of the upper lobe bronchus on the right is detected, which indicates obstructive atelectasis. Enlarged lymph nodes are detected in the right root.
Conclusion: central, predominantly endobronchial, cancer of the right upper lobe bronchus, complicated by atelectasis of the lobe and metastases to the lymph nodes of the right root.
X-rays of the chest organs in the straight line(Fig. 3.5 d) and right lateral projections after 2 months(after chemotherapy).
There is an almost complete disappearance of atelectasis with straightening of the upper lobe of the right lung. The lymph nodes of the right root have decreased somewhat.
X-rays of the chest organs in direct and right lateral projections. X-ray tomograms in a direct projection at 9.5 cm from the back (Fig. 3.5 d) and in the right lateral projection at 5 cm from the spinous processes 1 month after the previous X-ray examination.
Rice. 3.5. Patient F., 45. Atelectasis of the upper lobe of the right lung on radiography (a - radiograph of the chest cavity in a direct projection). Central, predominantly endobronchial cancer, complicated by obstructive atelectasis and metastases to the lymph nodes of the right root during tomography (b - X-ray tomogram in a direct projection 9.5 cm from the back; c - X-ray tomogram in the right lateral projection 5 cm from the spinous processes). After chemotherapy - almost complete disappearance of atelectasis, reduction of the lymph nodes of the right root (d - x-ray of the chest cavity in a direct projection). 1 month after the previous x-ray examination - progression of the process: total atelectasis of the right lung, the stump of the right main bronchus is visible (d - x-ray tomogram in a direct projection 9.5 cm from the back)
A total intense and uniform darkening of the right lung is visualized with a sharp shift of the mediastinum towards the lesion, the stump of the right main bronchus is visible.
Conclusion: progression of central, predominantly endobronchial, cancer with the development of total atelectasis of the right lung.
Protocol? 26
Patient M., 37 years old (Fig. 3.6).
X-rays of the chest organs in the straight line(Fig. 3.6 a) and left side(Fig. 3.6 b) projections.
On the left in S IV there is a ring-shaped shadow of a round shape, 5 cm in diameter with unclear outer and inner contours. The cavity wall of uneven thickness (from 0.5 to 1.0 cm) due to sequestration along the upper wall contains a horizontal level of liquid, occupying 2/3 of the volume. In the circumference of the cavity, there is an increase, blurriness and deformation of the pulmonary pattern. The left root is expanded,
Rice. 3.6. Patient M., 37 years old. Radiographs of the chest organs in the direct (a) and left lateral (b) projections. Abscess of the left lung in S IV.
unstructured. The right pulmonary field is transparent, the pulmonary pattern and root are not changed. The mediastinal shadow is not displaced, of normal size and configuration. The sinuses of the pleura are free. The diaphragm is located at the level of the VI rib, its shape is dome-shaped.
Conclusion: abscess of the left lung in S IV. Dynamic monitoring is required during the treatment process.
Protocol? 27
Patient S., 18 years old. X-rays of the chest organs in the straight line(Fig. 3.7) projections.
On the right in S III there is a ring-shaped shadow of a round shape, 6 cm in diameter, with thin, 0.1 cm thick, smooth, uniform walls, clear external and internal contours. Fluid in the cavity is not determined, the surrounding tissue is not changed. The left lung field is transparent.
Conclusion: single air cyst of the left lung in S III.
Rice. 3.7. Patient S., 18 years old. X-ray of the right half of the thoracic cavity organs in a direct projection. Single air cyst of the left lung in S TTT
Protocol? 28
Patient M., 9 years old. X-ray of the chest organs in a straight line(Fig. 3.8) projections.
On the left, occupying almost the entire pulmonary field, an oval-shaped shadow is found, measuring 15x4 cm with sometimes clear, sometimes fuzzy contours of a homogeneous structure. In the circle of the shadow there is a darkening of the average intensity of the inhomogeneous structure, merging with the described shadow. The left root is expanded, not structural. The right lung is transparent, the pulmonary pattern and root are not changed. The mediastinal shadow is not displaced, of normal size and
Rice. 3.8. Patient M., 9 years old. X-ray of the organs of the chest cavity in direct projection. Unopened hydatid cyst of the left lung, complicated by perifocal pneumonia
configurations. The sinuses of the pleura are free. The diaphragm is located at the level of the VI rib, its shape is domed.
Conclusion: unopened hydatid cyst of the left lung, complicated by perifocal pneumonia.
Protocol? 29
Patient Z., 24 years old (Fig. 3.9).
X-rays of the chest organs in the straight line(Fig. 3.9 a) and left side(Fig. 3.9 b) projections.
On the left, in S III, a rounded shadow is found, up to 3 cm in diameter with clear, even contours, of medium intensity; the impression of heterogeneity of the structure is created due to several centrally located large-clumpy calcifications. In the circumference of the shadow, the lung fields are transparent, as in the right lung. Pulmonary pattern on both sides is not changed. The roots are not expanded, structural. The sinuses of the pleura are free. The shadow of the mediastinum is not displaced, the usual size and configuration. The diaphragm is located at the level of the VI rib, its shape is domed.
Conclusion: hamartoma of the left lung in S III, however, X-ray tomography is necessary to clarify the structure of the shadow.
X-ray tomograms in direct projection 9.5 cm from the back(Fig. 3.9 c) and in the left lateral projection 5 cm from the spinous processes(Fig. 3.9 d).
The above-described characteristic of a pathological shadow with the presence in it of several centrally located large-block calcifications is confirmed.
Conclusion:
Radiograph of the drug removed during surgery(Fig. 3.9 d).
The X-ray picture of the specimen fully corresponds to the preoperative X-ray data.
Conclusion: hamartoma of the left lung in S III with calcification.
Rice. 3.9. Patient Z., 24 years old. Hamartoma of the left lung in S III on radiography: a - radiograph of the chest organs in a direct projection; b - radiograph of the chest organs in the left lateral projection. Hamartoma of the left lung in S III with calcification on tomography: c - X-ray tomogram of the chest organs in a direct projection 9.5 cm from the back; d - X-ray tomogram in the left lateral projection 5 cm from the spinous processes. Hamartoma of the left lung in S III with calcification on the radiograph of the specimen removed during surgery (e)
Protocol? thirty
Patient B., 61 years old.
X-rays of the chest organs in direct and left lateral projections.
On the left, a shadow of an irregular dumbbell-shaped shape, 4x6 cm in size, is found, consisting, as it were, of several merged nodes, with uneven, bumpy and radiant contours. A “path” is visible from the shadow to the root. The left root is structural, expanded due to two round shadows, 1.5 cm in diameter, which form the polycyclicity of the outer contour of the root. For the rest of the length, the left and right lungs are transparent, the pulmonary pattern is not changed. The right root is not expanded, structural. The shadow of the mediastinum of the usual location, somewhat expanded due to the left ventricle of the heart, the aorta has the usual location and diameter, compacted. No fluid is detected in the pleural cavity. The diaphragm is located at the level of the VI rib, its shape is dome-shaped.
Conclusion: peripheral cancer of the left lung in S, complicated by metastases in the lymph nodes of the root. To clarify the parameters of the tumor, X-ray tomography of the organs of the chest cavity is recommended.
X-ray tomograms of the organs of the chest cavity in the straight line of the left lung at a depth of 6 cm(Fig. 3.10) and left lateral (5 cm) projections.
The above described characteristic of the tumor is confirmed, the following are more clearly identified: a symptom of multinodularity of the pathological shadow, tuberosity and radiance of the contours, absence of decay, retraction of the interlobar fissure.
Conclusion: peripheral cancer of the left lung in S, complicated by metastases in the lymph nodes of the root.
Rice. 3.10. Patient B., 61 years old. X-ray tomogram of the organs of the chest cavity in the direct projection of the left lung at a depth of 6 cm.
Peripheral cancer of the left lung in S VI
Protocol? 31
Patient B., 61 years old. CT scan of the chest cavity (Fig. 3.11).
The study was carried out in sections, 8 mm thick, with a tomograph step of 1.6 cm from the level of the I thoracic to the XII thoracic vertebrae.
On the left in S VI there is a hyperdense formation of irregular shape, measuring 3x4 cm, of a heterogeneous structure with tuberous and radiant contours, there is an eccentrically located hypodense lesion of irregular shape, measuring 1.5x2 cm, without a fluid level. There is an intimate connection between the posterior contour of the formation and the parietal pleura, the latter in this zone is thickened, but there is no fluid in the pleura. Other parts of the right lung and left lung are not changed. There is a “path” from the described formation to the right root; enlarged lymph nodes are visible at the root. No enlarged lymph nodes or other pathological changes were found in the mediastinum.
Conclusion: peripheral cancer of the right lung in S, complicated by decay, invasion of the parietal pleura and metastases to the lymph nodes of the left root
Rice. 3.11. Patient B., 61 years old. CT scan of the chest cavity.
Peripheral cancer of the left lung in S VI, complicated by decay, invasion of the parietal pleura and metastases to the lymph nodes of the left root
Protocol? 32
Patient M., 56 years old (Fig. 3.12).
X-ray images of the chest cavity organs in the straight line (left lung, rice. 3.12 a) and left side(Fig. 3.12 b) projections.
Rice. 3.12. Patient M., 56 years old. Central, predominantly exobronchial cancer of the left lung without obstruction of bronchial patency on radiography:
a - X-ray of the organs of the chest cavity in direct projection; b - radiograph of the chest organs in the left lateral projection. Central, predominantly exobronchial cancer of the left lung without obstruction of bronchial patency with metastases to the lymph nodes of the root with tomography: c - X-ray tomogram of the chest cavity in a direct projection 9.5 cm from the back; d - X-ray tomogram in the left lateral projection 9 cm from the spinous processes
In the left root there is a shadow of an irregular hemispherical shape, measuring 4x6 cm, with uneven tuberous and radiant contours. Throughout the rest of the length, the left and right lungs are transparent, the pulmonary pattern is not changed. The left root merges with the above-described darkening. The right root is not expanded, structural. The mediastinal shadow has a normal location, slightly expanded due to the left ventricle of the heart, the aorta has a normal location and diameter, and is compacted. No fluid is detected in the pleural cavity. The diaphragm is located at the level of the VI rib, its shape is dome-shaped.
Conclusion: central, predominantly exobronchial, cancer of the left lung without impaired bronchial patency. To clarify the parameters of the tumor, X-ray tomography of the organs of the chest cavity is recommended.
X-ray tomograms of the chest cavity organs in a straight line (at a depth of 9.5 cm, rice. 3.12 c) and left lateral (by 9 cm, rice. 3.12 g) projections.
The above described characteristic of the tumor is confirmed, the tuberosity and radiance of its contours are more clearly revealed. In addition, enlarged lymph nodes in the left root are detected.
Conclusion: central, predominantly exobronchial, cancer of the left lung without impaired bronchial patency, complicated by metastases in the lymph nodes of the root.
Protocol? 33
Patient X., 32 years old (Fig. 3.13).
X-rays of the chest organs in the straight line(Fig. 3.13 a) and right side(Fig. 3.13 b) projections.
On the right, the lower half of the pulmonary field is darkened. The darkening is intense, uniform, its lower border merges with the diaphragm, the upper is concave, obliquely ascending from the anterior end of the third rib to the lateral surface of the first rib (Damoiso line). In the right lateral projection, it is noted that the darkening occupies the peripheral parts of the pulmonary field. The left pulmonary field is transparent, the pulmonary pattern is not changed. The sinuses of the pleura are free. The mediastinal shadow is shifted to the left, of normal size and configuration. The right dome of the diaphragm is not differentiated, the left one is located at the level of the VI rib, its shape is dome-shaped.
Conclusion: right-sided exudative pleurisy.
Rice. 3.13. Patient X., 32 years old. Right-sided exudative pleurisy: a - radiograph of the chest organs in a direct projection; b - radiograph of the chest organs in the left lateral projection
Protocol? 34
Patient M., 56 years old. X-rays of the chest organs in the straight line(Fig. 3.14) and left lateral projections.
On the left, darkening of the pulmonary field is detected throughout its entire length. The darkening is intense, uniform, its lower border merges with the diaphragm, its upper border merges with the apical pleura. The right pulmonary field is transparent, the pulmonary pattern is not changed. The sinuses of the pleura are free. The shadow of the mediastinum is shifted to the right; it is not possible to judge its size and configuration. The left dome of the diaphragm is not differentiated, the right one is located at the level of the VI rib, its shape is dome-shaped.
Conclusion: left-sided total exudative pleurisy.
Rice. 3.14. Patient M., 56 years old. X-ray of the organs of the chest cavity in direct projection. Left-sided total exudative pleurisy
Main
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