Radiation diagnosis of chest injuries. Algorithms of ray research methods
Radiation diagnosis in traumaRadiation diagnostics plays an important role in the primary examination of patients with trauma and in 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 helical CT, angiography, and RT, to make a definitive diagnosis and exclude injuries. Improving the methods of radiation diagnostics has made it possible to increase the accuracy of the information obtained and reduce the time of examination, and the development of endovascular methods of treatment has created an alternative to traditional surgical interventions for some vascular injuries.
The choice of method of radiation diagnostics is individual and depends on a number of factors, which are listed below.
- Availability of equipment for conducting a particular study and its proximity to the place of provision of EM P.
- The quality and speed of obtaining information using the available equipment.
- Availability of specialists in radiation diagnostics and experience in conducting emergency examinations.
- The presence of specialists who can analyze the information received.
- The ability to timely transfer the results of the study to other specialists.
- The ability to control basic physiological parameters, maintain vital functions, including resuscitation, in case 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 a study and its duration is the stability of the patient's hemodynamics. With severe shock and the ineffectiveness of the first stage of EMT, any study may be unsafe. The only study that can be done is a bedside ultrasound to look for fluid in body cavities. If a patient is admitted in a state of shock but treated effectively, bedside x-rays of the chest, pelvis, and spine can be performed, while transporting them to other departments for CT or MRI is dangerous. With initially stable hemodynamics in the absence of deterioration of the patient's condition at the first stage of EMT, if necessary, CT or MRI can be performed. Optimal use of imaging modalities requires close collaboration and collaboration between trauma surgeons, nurses and research staff. A specialist in radiation diagnostics can and should help the trauma surgeon to select the necessary studies and determine their order in order to fully answer the questions that have arisen in a particular clinical situation.
RADIATION DIAGNOSIS IN CHEST INJURY
X-ray of the chest in the posterior direct projection allows you to accurately diagnose pneumothorax, including tension, pneumomediastinum, pneumopericardium, Bruising, -a; m. Mechanical damage to the body without violating the integrity of the outer integument, accompanied by rupture of small vessels and hemorrhage, violation of the integrity of the subcutaneous tissue, muscle fibers, and sometimes - ext. organs (liver, spleen, etc.).
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Urgent Care. After exclusion of possible damage to internal organs, antishock therapy is performed.
chest compressions possible in case of accidents at work, car injuries and other situations. The diagnosis is made on the basis of signs of the so-called traumatic asphyxia: the head, face and chest of the victim acquire a purple-violet color with a pronounced 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 during impact, fall, compression of the chest and can be single and multiple, with or without displacement. With displacement, complications are possible in the form of damage to the intercostal vessels and nerves, the pleura and lung, with the formation of various types of pneumothorax, hemothorax, subcutaneous emphysema.
Diagnostics is based on anamnesis, localized pain syndrome, interconnected with breathing, chest movements, cough. Reliable signs of a rib fracture include the presence of pathological mobility of rib fragments, crepitus of bone fragments and deformity of the chest (with multiple fractures). With multiple fractures, a state of shock may develop with signs of ARF of stages I-III.
The leading additional method for diagnosing rib fractures is chest x-ray. It should be noted once again that a negative response in 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. Urgent hospitalization in the surgical department.
Fracture of the sternum usually happens on the border of her body and the handle or the xiphoid process. There is a typical localized pain associated with breathing. Differential diagnosis is made, first of all, with coronary artery disease.
Urgent Care: anesthesia is performed in / m or / in the introduction of 2-4 ml of 50% solution of analgin. With severe pain, novocaine or alcohol-novocaine blockade is indicated at the fracture site. Surgeon's consultation.
4.8. Syndrome of prolonged compression,principles of treatment (crash syndrome):
The principles of treatment of SDS are most successfully formulated by R. N. Lebedeva et al. (1995):
Support of blood circulation and respiration (volemia correction, cardiotonic, catecholamines, blood components, mechanical ventilation);
Timely surgical, traumatological care (fasciotomy, necrectomy, osteosynthesis, amputation of limbs, plasty 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 blood pH is below 6.0, a renal block occurs (Lalich J., 1955). In these cases, the free hemoglobin in the plasma begins to turn into hematin hydrochloride, which is retained in the tubules, which contributes to the formation myoglobinuric nephrosis, which is not observed in alkaline urine. Prevention of this complication is achieved by alkalization of the plasma by intravenous drip injection of 4% solution of sodium bicarbonate until an alkaline urine reaction is obtained.
2. Correction of disturbed rheological properties of blood is achieved by using heparin, trental, fibrinolytically active or fresh frozen plasma.
Amount of assistance at the site of injury. Before releasing the affected from the rubble, it is necessary to prevent ischemic toxicosis in the following sequence: anesthesia with analgesics, the introduction of alkaline blood substitutes into the 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 blood, then it is necessary to apply a tourniquet proximal to the place of compression. After that, the affected person is released, taken out to a safe place and the tourniquet is replaced with a tight bandage of the compressed tissues of the limb, and the compressed parts of the body are covered with coolant bags. This is necessary to restore blood flow in compressed tissues in a limited, gentle mode, as well as in ischemic tissues, which makes it possible to prevent their destruction, toxicosis and reactive hyperemia. The entire volume of prehospital care is completed with tissue cooling and transport immobilization.
4.9. Limb injuries in the wounded, the affected are divided into open and closed. Among the latter, firearms and non-firearms are distinguished. 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 syndrome (local pain, aggravated by the slightest movement); limb segment deformity; pathological mobility and crepitus in the area of the fracture; the presence of swelling. Gunshot fractures are divided into incomplete and complete. Among the latter, transverse, longitudinal, oblique, fragmented are distinguished. Among the fractures of long tubular bones, there are fragmental and multi-comminuted fractures. Recognizing them is not very difficult - with these fractures, the following are noted: limb deformity, pathological mobility, crepitus in the fracture area.
The sequence of rendering - first medical aid, pre-medical, first medical aid on the PMP to the wounded, affected by fractures of the limbs is as follows:
anesthesia;
Imposition of an aseptic dressing on the wound, wound toilet (hydrogen peroxide, chlorhyxedine, etc.), use of the aerosol "cimezol", with which you can stop the development of a wound infection up to 2-3 days;
transport immobilization with fixation of two adjacent segments of the injured limb.
Before applying splints to bare limbs, they should be wrapped with cotton-gauze pads. Immobilizing splints must be attached with bandages throughout the limb. The main danger in bandaging is constriction of the limb. In the cold season, after applying the splint, the limb must be insulated.
During transport immobilization of damaged limbs, splints can be applied over clothes and shoes.
Methods of transport immobilization depend on the location of the damage.
In case of shoulder fractures, the upper limb is immobilized using a pre-modeled ladder splint (Cramer 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 is fixed in the middle position between pronation and supination. The shoulder is brought forward beyond 30 ° and somewhat removed from the body. The proximal end of the splint is connected to the distal end with two gauze ribbons covering the chest on the opposite side of the body to the fracture in front and behind. The tire is fixed with a gauze bandage.
For fractures of the forearm, a ladder splint is applied from the upper third of the shoulder to the metacarpophalangeal joints. The forearm is fixed in the same position as in case of fractures of the shoulder. Additionally, a scarf is used.
In case of fractures of the lower leg, three stair splints are applied: the back splint, modeled according to the contours of the calf muscles and the heel, as well as two tibial splints. For all fractures of the lower extremities, the foot is fixed in the position of 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 perianchips must be wrapped with cotton, which rest against the affected person in the axillary and inguinal-perineal region, as well as the inner surface of the branches, then the damaged limb is stretched along the length, eliminating rotational displacement with a twist on plywood sole. The tire is attached to the body with cloth bandages.
For immobilization of hip fractures, multiple fractures, you can use the anti-shock suit "Kashtan", 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 splints listed above, three types of plastic splints are used to immobilize damaged bones: type 1 - 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 splints and combined dressings can be used as means for medical-transport immobilization.
In table. 5. data on the sequence of revealing the nature of injuries and urgent measures at the prehospital stage are summarized in a single system.
Table 5. Identification of the nature of damage to the affected and
emergency medical care at the scene
| Subsequence inspection and detection of damage | Objective data, clinical manifestations | Emergency medical care |
| Determination of the integrity of blood vessels | - pale face - ineffective attempt to inhale - vomit on the face - obstruction to breathing in the mouth (foreign body) | - cleaning of the oral cavity, removal of a foreign body - tracheal intubation, - artificial ventilation of the lungs |
| 1. Examination of the head, spine: - craniocerebral injuries, gunshot and non-gunshot wounds: soft tissues; non-penetrating, penetrating wounds 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 | - stop external bleeding - cold on the head - aseptic dressing - cordiamine or caffeine solution - lytic mixture: |
| - damage to all membranes and the brain - bleeding from the ear, nose - unilateral, bilateral exophthalmos - violation of the rhythm of breathing - lack of corneal reflexes, wandering eyeballs - damage to the brain stem. | chlorpromazine - 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 injury with spinal cord injury | - damage to soft tissues, muscles, vertebral bodies - detection of motor disorders, trophic disorders, pelvic disorders | - stop external bleeding, aseptic dressing - anesthesia of the cervicothoracic spine - transport immobilization |
| - maxillofacial region | - deformity 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, shoulder blades; multiple rib fractures | - shortness of breath, suffocation, hemoptysis, open bilateral pneumothorax, frequent shallow breathing - SBP - 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 2nd-3rd intercostal space along the midclavicular line with the connection of the petal valve - anesthesia - vagosympathetic blockade novocaine solution - 0.25% 60 ml per PMP - cardiac |
| 3. Inspection 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 - tension of the muscles of the abdominal wall - bloating, positive symptom of Shchetkin-Blumberg - absence of noise during auscultation of the abdomen - dullness during 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, bladder; rectum, posterior urethra, prostate | - tension of the muscles of the abdominal wall - hematuria - penetration of urine into the wound - exit of feces through the wound - deformity of the pelvis - presence of a defect in the pubic area | - aseptic dressing - anesthesia - cardiac - bladder catheterization |
| 5. Examination of firearm and non-firearm limbs; with damage to soft tissues, joints | - pathological mobility - bone crepitus - visible deformity of the limb in the area of fracture of the diaphysis and epiphysis - shock 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 liters | for wounds: - aseptic dressing - anesthesia - immobilization of limbs |
| 6. Massive detachment of skin and fiber | - softening in the subcutaneous tissue | - aseptic dressing |
4.10. Under polytrauma understand multiple or combined trauma that poses a danger to the life or health of the affected person and requires emergency medical care.
Pre-medical, first medical aid for polytrauma at the scene of the incident provides for:
restoration of patency of the upper respiratory tract;
stop external bleeding by applying an aseptic bandage or tourniquet;
anesthesia;
immobilization of fractures with standard splints;
infusion therapy for shock, SDS, burns;
Preparing the casualty for evacuation.
At the scene of the incident, during examination and sorting of the affected, two groups are distinguished - those who are conscious and unconscious. Among those who are conscious, they determine who needs emergency medical care in specialized and general surgical departments, and those who, after first aid can be delayed, are evacuated secondarily to general surgical departments. Those who are unconscious and those who, after rendering first aid, did not return, are evacuated first of all lying on their side 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 mechano-thermal damage occurs under the action of mechanical and thermal factors with the predominant action of the mechanical factor. In those affected with combined thermomechanical lesions, traumatic and burn shock most often develops and is severe. According to the degree of severity, combined thermomechanical damage can be conditionally divided into four groups (Table 6).
Table 6. Classification of mechanical and thermal damage
by severity
| Injury severity | Burn severity | Mechanical damage |
| Light | 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 of small bones of the limb, fractures of the clavicle. Mild concussion |
| Medium | I - III A (10 - 20% of the body surface), III B - IV (up to 10% of the body surface) | Wounds with damage to the tendons and an extensive area of soft tissue damage. Dislocations in the large joints of the limbs, avulsion fractures of the ribs, pelvic bones, one of the paired tubular bones. Open fractures of the bones of the foot. Isolated fractures of the spine. Compression, concussion of moderate and severe degree |
| heavy | I - III A (20 - 30% of the body surface); III B - IV (10 - 20% of the body surface) | Wound of soft tissues with damage to the nerves and opening of large joints. Closed multiple fractures of the pelvic bones, limbs. Open isolated fractures of large bones of the limbs with a small area of soft tissue damage. Fractures of the spine with damage to the spinal cord, fractures of the bones of the skull. Limb compression |
| Extremely heavy | I - III A (31 - 50% of the body surface); III B- IV (more than 20% of the body surface) | Wound with damage to the main 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 spinal cord injury. Multiple fractures of the bones of the skull, its base. |
The urgent measures of pre-medical, first medical aid for combined mechano-thermal injuries of the affected person include:
stop bleeding by applying an aseptic bandage, ligation of a bleeding vessel;
in exceptional cases and for the shortest possible time - the imposition of a tourniquet on a burnt limb;
tracheostomy for severe burns of the upper respiratory tract, intubation with an air duct;
cutting off non-viable burnt limbs hanging on a skin flap;
The imposition of an aseptic bandage on the burnt surface;
· with a burn surface of not more than 1% of the body surface - irrigation with chlorethyl, aseptic dressing after the toilet of the wound;
evacuation of the affected to the next stage.
Principles of treatment of burn shock
After relief of pain 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 protective and adaptive functions of the body. Infusion therapy for the treatment of burn shock is presented in Table. 7.
Table 7. Transfusion therapy program for burn shock
(V. A. Klimansky, Ya. A. Rudaev, 1984)
By protocol ATLS(life support of the victims in the first hours of injury) if a spinal injury is suspected, the initial clinical assessment should precede the corresponding radiological examination. As follows from the 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 evaluation of the cervical spine begins with a lateral cross table (horizontal direction of the x-ray beam; the patient is in a horizontal position on the back) projection (CTLV), which allows to detect 70-79% of all lesions.
side shot should display the entire cervical region, including the cervicothoracic junction. The addition of AP and oral exposures increases the productivity of plain radiographs by up to 90-95%. Injuries to the cervical region mainly concern the C2 vertebra and C5-C6 motor segment.
Diagnosis of instability X-ray with stress flexion-extension tests contributes greatly, 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 not able to voluntarily and fully perform flexion and extension of the spine.
With negative survey results and persistent clinical symptoms, functional radiography is prescribed 2-3 weeks after the injury.
All patients with multiple trauma, 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 holding 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, head CT 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 RAY RESEARCH METHODS Prof. B.N. Sapranov Izhevsk State Medical Academy Course of Radiation Diagnostics and Radiation Therapy Prof.
- - Standard..." target="_blank"> 2. LEVELS OF RADIATION ALGORITHMS
- - Standard radiography
- - General purpose ultrasound
- - Linear tomography
- Television fluoroscopy
- - All Level I methods
- - Spec. radiography techniques
- - Spec. ultrasound techniques, including dopplerography
- - Mammography
- - Osteodensitometry
- - Angiography
- - CT
- - Radionuclide methods
- - All methods of level I and II
- - MRI
- - PET
- - Immunoscintigraphy
- Informativeness..." target="_blank"> 3. Principles for choosing a visualization method
- informative
- The lowest level of exposure
- Minimum cost
- Radiologist Qualification
- Diseases..." target="_blank"> 4. Headache syndrome Main causes
- CNS diseases
- Anomalies of the QUO
- Hypertonic disease
- Vertebrobasilar insufficiency
- Level I Skull x-ray
- Norm Intracranial Intracranial hypertension calcification
- Radiography of the cervical
- spine
- Level II CT, MRI CT, MRI CT
- 6. Intracranial calcifications MeduMed.Org - Medicine is Our Vocation
- 8. Lateral synostosis and spondylolysis C6-C7
- ORGANS OF THE CHEST MeduMed.Org - Honey..." target="_blank"> 9.
- ORGANS OF THE CHEST
- 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 of radiological examination in acute chest pain syndrome of non-cardiac localization NORMAL PAT. BONES? ESOPHAGUS PAT? PNEUMOTHORAX? TELA? MEDIASTINUM? PLEURISY? PRIC. IMAGE EXAMINATION GRAPHICS IMAGE ULTRASOUND Ur. 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. Coronarosclerosis MeduMed.Org - Medicine is Our Vocation
- 20. Diaphragmatic hernia MeduMed.Org - Medicine is Our Vocation
- Main reasons
- 1) coronary artery disease
- 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. Radiation examination algorithm 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 RDI of the esophagus, Doppler of the stomach AKG, Aortography Coronary angiography. CT with contrast.
- Level III
- MRI
- 23. Lung hypostasis MeduMed.Org - Medicine is Our Vocation
- 24. Aneurysm of the left ventricle MeduMed.Org - Medicine - Our Vocation
- 25. Aortic Aneurysm MeduMed.Org - Medicine is Our Vocation
- 26. Cardiomegaly
- 27. Aortic stenosis
- 28. Constrictive pericarditis MeduMed.Org - Medicine is 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 disease
- 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. Imaging Algorithm for Breathlessness
- Level I CHEST RADIOGRAPHY
- 32. Emphysema
- 33. Wegener's granulomatosis
- 34. Primary pulmonary hypertension
- 35. Foreign body in the bronchus
- 36. Exogenous alveolitis
- 37. Scleroderma MeduMed.Org - Medicine is Our Vocation
- 38. Scleroderma
- 39. Pulmonary berylliosis
- 40. Sarcoidosis of the lungs MeduMed.Org - Medicine is Our Vocation
- 41. TELA MeduMed.Org - Medicine is 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 anomalies
- Level I Chest X-ray Diagnosis is clear Diagnosis is not clear Linear tomography Functional X-ray (Sokolov's test)
- Level II CT, APG
- 45. Hematogenous disseminated pulmonary tuberculosis
- 46. Bronchiectasis
- 47. Bronchiectasis
- 48. Broncholithiasis MeduMed.Org - Medicine is Our Vocation
- 49. Chronic bronchitis I stage. MeduMed.Org - Medicine is Our Vocation
- 50. Chronic bronchitis III stage.
- 51. Central lung cancer MeduMed.Org - Medicine is Our Vocation
- 52. Hypoplasia of the left pulmonary artery MeduMed.Org - Medicine - Our Vocation
- Main causes..." target="_blank"> 53. Hemoptysis and pulmonary hemorrhage
- Main reasons
- 1) Tumors of the lungs (central cancer, bronchus adenoma)
- 2) PE, pulmonary infarction
- 3) Croupous pneumonia
- 4) Pulmonary tuberculosis
- 5) Anomalies of the lungs (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 is Our Vocation
- Main reasons
- 1) ..." target="_blank"> 60. Sharp belly
- Main reasons
- 1) Hollow organ perforation
- 2) Intestinal obstruction
- 3) Acute appendicitis
- 4) Cholelithiasis
- 5) Acute pancreatitis
- 6) Abscess of the abdominal cavity
- 7) Renal colic
- 61. Algorithm of radiological examination in acute abdomen syndrome
- Level I Plain radiograph of the abdomen, ultrasound The picture is clear The picture is not clear
- Laterogram
- Level II X-ray contrast study, CT
- 62. Hollow organ perforation MeduMed.Org - Medicine - Our Vocation
- 63. Intestinal obstruction MeduMed.Org - Medicine - Our Vocation
- 64. Right 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 ORGANS OF THE CHEST CAVITY
CHAPTER 3 RADIATION DIAGNOSIS OF DISEASES OF THE ORGANS OF THE CHEST CAVITY
JUSTIFICATION OF THE NEED TO STUDY 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 make a correct diagnosis, the attending physician must first prescribe an X-ray examination of the lungs, which remains the main method of diagnosis. The information content of X-ray and other radiation methods in the diagnosis of a particular lung disease will be discussed in this chapter.
AUXILIARY MATERIAL
The following material is given 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.
of the chest cavity, about radiation methods and techniques, about their informativeness in various diseases of the lungs and mediastinum, about the X-ray semiotics of the main pathological conditions and their differential diagnosis.
Fundamental questions and answers
Question 1. What do the organs of the chest cavity look like on x-rays in frontal projection?
Answer.In direct projection, the right and left lungs look in the form of enlightenment due to the air in the alveoli, and between them the shadow of the mediastinum is visible (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 top of the lungs), as well as shadow stripes of vessels and bronchi that form lung drawing, fan-shaped diverging 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 II to IV ribs along the anterior ends, its width is 2-2.5 cm.
Shadow of the mediastinum has three departments:
Upper (up to the level of the aortic arch);
Average (at the level of the aortic arch, here the thymus gland is located in children);
Lower (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 from below aperture, each half of it has a domed shape, located at the level of the VI rib (on the left, 1-2 cm lower).
Pleura forms in direct projection the right and left costal-diaphragmatic and cardio-diaphragmatic sinuses, which normally give a triangular shape of enlightenment.
Question 2. Are there any features in the shadow picture of the organs of the chest cavity in the lateral projection?
Answer. In the shadow picture of the organs of the chest cavity in the lateral projection, the features are that both lungs overlap each other, so this projection cannot be analyzed independently,
and must be combined with a direct projection in order to present a planar image as a three-dimensional one.
Lateral projections must be done in two (left and right): in this case, that half of the chest that is adjacent to the film is better visible.
Against the background of the lung fields are visualized shadows of bone formations: in front - the sternum, behind - III-IX thoracic vertebrae and scapula, the ribs go in an oblique direction from top to bottom.
lung field seen 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 of 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 enlightenment of the trachea, coming from the neck, breaks off, since the division of the trachea into bronchi passes in the root area.
Sinuses of the pleura in the form of triangular enlightenments, limited below by the diaphragm, in front - by the sternum, behind - by the spine, these are the anterior and posterior:
Cardio-diaphragmatic;
Rib-diaphragmatic.
Question 3. How many lobes and segments are in the right and left lung? What are the interlobar fissures on the 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;
In the left - 2 lobes (upper, lower) and 9 segments (no VII). There are oblique and horizontal interlobar fissures.
Oblique interlobar fissure separates:
The upper lobe 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 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 III 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:
In direct projection, its course is horizontal from the outer edge of the IV rib to the root;
In a lateral projection, it departs from the oblique fissure at the level of the root and goes horizontally towards the sternum.
Question 4. What is the algorithm for the use of radiation methods and techniques in diseases of the organs of the chest cavity and what are the goals of their application?
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.
- Fluoroscopy 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 in vascular formations;
Changes in the lung pattern during breathing;
Movement of fluid in pathological cavities and in the pleural cavity with a change in body position;
Heart contractions.
Multi-axis polypositional examination provides the choice of the optimal projection for radiography, including pinpoint images
Fluoroscopy is used in interventional radiology, those. under her control, punctures of various formations of the chest cavity, cardioangiography, etc. are carried out.
- Plain radiography organs of the chest cavity in direct and lateral (right and left) projections allows:
Detect pathological changes;
Set their localization;
Clarify the various symptoms of diseases of the lungs, pleura and mediastinum.
- Tomography- layered longitudinal study, in two projections (direct and lateral), it contributes to:
Obtaining a clearer image of pathological shadows, as it eliminates the layering of surrounding tissues;
Establishment of any morphological type of changes in the organs of the chest cavity;
Visualization of the lumen of the bronchi.
This technique is obligatory and the most informative for all diseases of the organs of the chest cavity. It is usually carried out after a plain radiography, in which the depth of the necessary tomographic sections 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 in the introduction of high-contrast substances into the vessels under the control of fluoroscopy, then radiography is carried out in two projections and the analysis of the resulting picture. Technique: through the artery of the elbow bend, the catheter is passed further through the right atrium and the right ventricle of the heart into the pulmonary trunk, the vessels of the lungs and heart are contrasted, their condition is determined.
CT gives transverse sections of the organs of the chest cavity (transverse), while assessing the condition:
Alveoli;
Vessels;
Bronchov;
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 step in the development of the method, it uses three projections (transverse, frontal, sagittal), and therefore is more informative in assessing the state of the above objects.
ultrasound lungs are practically not used at present due to the fact that the study is hindered 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;
Darkening of low or medium intensity;
Displacement of interlobar fissures towards darkening;
The mediastinum on inspiration is shifted to the affected 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. Radiological manifestations of valvular obstruction.
Increased transparency of the lung field in the area of impaired ventilation.
Impoverishment of the pulmonary pattern.
An increase in the volume of the lung area, as evidenced by:
Displacement of interlobar fissures in the opposite direction;
Bulging of the lung tissue through the intercostal spaces;
Horizontal arrangement of ribs;
Mediastinal displacement in the opposite direction.
Complete obstruction bronchus leads to a decrease in the volume of the corresponding section of the lung due to subsidence, since air does not enter the alveoli. It is called atelectasis and on X-ray examination has the following manifestations:
Intense uniform darkening;
Displacement of interlobar fissures towards the lesion;
Shift of a mediastinum towards darkening.
Question 6. What are the main pathological radiological syndromes detected during the examination of the organs of the chest cavity, in what diseases do they occur?
Answer. The main pathological radiological syndromes detected during the examination of the chest organs, and the diseases in which they occur, are as follows.
Extensive blackout(due to compaction of the lung tissue or lung field):
Atelectasis of the entire lung (mediastinum shifts towards the lesion);
Condition after pulmonectomy, when fibrothorax is observed (mediastinum shifts to the affected side);
Inflammatory infiltration - pneumonia (mediastinal organs are not displaced or slightly displaced in the opposite direction);
Tuberculosis (with bilateral lesions, the mediastinum is shifted towards more massive changes): infiltrative, fibrous-cavernous, hematogenous disseminated, caseous pneumonia;
Pulmonary edema (mediastinum is not displaced);
Hydrothorax, when fluid fills the entire pleural cavity (the mediastinum is displaced in the opposite direction).
Limited dimming with lobar lesions (the mediastinum is displaced in one direction or another, depending on the nature of the changes):
Lobar or segmental atelectasis;
Lobar or segmental pneumonia;
Tuberculous infiltrate;
lung 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):
Spherical 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 annular shadow);
Polycystic lung disease (multiple annular shadows);
Emphysematous bullae (multiple annular 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 annular shadows);
Peripheral cancer with decay (single annular 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:
Lung swelling (emphysema);
Pneumothorax (with varying degrees of lung collapse towards the root);
It can be like a condition after a pulmonectomy.
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 the pulmonary pattern observed in many diseases:
Acute and chronic pneumonia;
Violation of blood circulation in the small circle;
Peribronchial cancer;
Interstitial metastases;
Tuberculosis;
Occupational diseases, etc.
There are three main options for changing the lung 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 (rapprochement, shortening and expansion of the bronchi).
- Weakening pulmonary pattern is observed less frequently, while 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 versions.
- root extension, what could be related:
With stagnation of blood in large vessels;
With an increase in 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 cellulose or its fibrosis (for example, of an inflammatory nature).
Question 7. What are the urgent conditions of the lungs and diaphragm associated with, 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 trauma;
With spontaneous opening of the lung cavity (cyst, bulla, etc.) into the pleura.
An x-ray examination is carried out immediately in the x-ray room, intensive care unit, operating room and elsewhere, 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, contrast glass, etc.);
quantities;
Localizations;
Sizes;
The state of the surrounding tissues.
fractures ribs, collarbones, sternum, vertebrae. An X-ray examination determines:
Their localization
Fracture line direction
fragment displacement,
The presence of a hematoma, etc.
Pneumothorax(air in the pleura) appears:
In case of damage to the lung in cases of closed injury;
With an open injury with damage to the pleura (for example, a broken rib);
With spontaneous opening of the lung cavity into the pleura. X-ray 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);
Mediastinal displacement in the opposite direction.
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 one, when vertical, 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 displaced in the opposite direction.
Hemothorax appears when the pleura is damaged, then blood or fluid accumulates in it and there is no air, therefore, radiologically, in a vertical position, not a horizontal, but an oblique level of fluid is formed, which spreads in a horizontal position and creates a diffuse darkening of the pulmonary field, as in exudative pleurisy, the mediastinum is displaced into opposite side.
Emphysema of the soft tissues of the chest occurs when gas from the pleural cavity is distributed between the muscle fibers, creating radiologically the so-called "feathery" pattern on x-ray examination.
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 "edging".
Hemorrhage in the lung parenchyma, on x-ray examination, it manifests itself in the form of blackout areas, different in intensity, size and shape.
Diaphragm injury. radioscopic signs.
High location.
Restriction of mobility.
The appearance of fluid in the pleural sinuses of the corresponding side.
Discontinuity of the contour of the dome of the diaphragm.
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 is the essence and radiographic manifestations of polycystosis?
Answer. Polycystic- a congenital disease associated with underdevelopment of lung tissue, often within a lobe or segment. In this case, the lung tissue is replaced by multiple air cysts, the volume of the corresponding area of the lung is reduced.
Radiological manifestations of polycystic:
Multiple annular shadows with thin uniform walls, which creates a symptom of "soap bubbles";
At the bottom of the cavities, horizontal levels of liquid appear if an inflammatory process occurs against this background;
Interlobar fissures are shifted towards the lesion, which indicates a decrease in the volume of the lesion;
The shadow of the mediastinum for the same reason is also shifted towards pathological changes;
On tomograms and bronchograms, it can be seen that the bronchi are deformed due to their underdevelopment, anatomically fully formed bronchi in the zone of changes are not determined.
Question 9. There are two main forms of acute bacterial (pneumococcal) pneumonia, depending on the volume and nature of the lesion of the lung parenchyma. What are these forms, what is their X-ray semiotics, and what is the time for X-ray examination in the diagnosis of these conditions?
Answer. Depending on the volume and nature of the lesion of the lung parenchyma, the following are distinguished: forms of acute bacterial (pneumococcal) pneumonia:
Parenchymal pneumonia occupies part of a segment, a segment, a lobe, or even the entire lung.
pathoanatomically hyperemia occurs, sweating of the liquid part of the blood into the alveoli, due to which their airiness becomes less.
X-ray semiotics:
Darkening of the corresponding area of the lung;
The volume of the lesion of the lung increases somewhat, as evidenced by the displacement of the interlobar fissures, and sometimes 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 fuzzy contours;
The intensity of blackout is average, increases towards the periphery;
Heterogeneous structure, against the background of darkening, light stripes of unchanged bronchi are visible;
The root on the side of the lesion is expanded and non-structural ("lubricated") due to inflammatory infiltration;
At the root, lymph nodes enlarged due to hyperplasia in the form of round shadows are visible;
An oblique fluid level may appear in the pleura, usually little beyond the external costophrenic sinus (with complication of 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;
Darkening medium intensity;
The structure is heterogeneous;
Contours are fuzzy;
Shadows can merge.
Difficulties arise in the differential diagnosis with tuberculosis, the distinguishing features are as follows:
The number of foci with tuberculosis increases towards the top of the lung, and with pneumonia - towards the diaphragm (the tops are not affected);
With dynamic observation in case of tuberculosis, the foci disappear after 12 months, and in case of pneumonia - after 2 weeks.
Time of X-ray examination in the diagnosis of pneumonia consists of the following stages.
At the initial visit to the doctor, but if it is clinically pneumonia, and it is not detected radiographically, then a re-examination is mandatory after 2-3 days from the onset of the disease, since on the first day there is still no infiltrate in the lungs (there is no blackout), but there is only hyperemia (increased pulmonary pattern due to the vascular component), which is often overlooked.
A study after 2 weeks for dynamic control and resolving the issue of the nature of the course of the disease:
If acute the course of the disease, the infiltrate disappears;
If subacute- the infiltrate does not disappear, but is fragmented, its intensity and heterogeneity increase;
If complicated course, then abscess formation, pleurisy, etc. appears.
If after 2 weeks there are no changes in the infiltrate (darkening) in the direction of its decrease, then this is an indication for tomography,
which will allow you to establish the primary or secondary nature of inflammatory changes.
A study after 1 month is carried out with a subacute or protracted course of the disease. By this time, the infiltrate (blackout) should disappear, if not, then the tomography is repeated, and, if necessary, bronchography and CT.
After 2 months, an x-ray examination is carried out with a protracted course, and if the infiltrate does not disappear after 1 month, then the transition of the disease to a chronic course or a 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 bronchiectasis, What is the volume of the affected area of the lung, radiological signs and the most rational algorithm for using radiological techniques to detect 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 lung parenchyma due to repeatedly transferred acute pneumonia, i.e. chronic inflammation. At the same time, the corresponding area of the lung lesion decreases in volume due to fibroatelectasis.
radiological signs.
Darkening is intense.
The structure of the blackout is heterogeneous, the volume of the blackout 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 there are two types of bronchiectasis:
Cylindrical (expansion along 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.
Bronchial deformation is also noted in adjacent segments. Rational algorithm X-ray techniques for the detection of bronchiectasis.
First do survey radiographs in direct and corresponding lateral projections, they reveal a darkening of the lobe or
segment with a decrease in their size and other signs of atelectasis listed above.
Direct superexposed radiograph(with the help of rays of increased rigidity) allows you to determine the structure of the darkening and, possibly, to see the lumen of the bronchi.
Tomograms in direct and lateral projections are more informative for visualizing the lumen of the bronchi, while the presence of bronchiectasis can be suspected.
Bronchography(introduction of contrast into the lumen of the bronchi) in two projections allows you to most accurately determine the presence, nature and prevalence of bronchiectasis.
CT carried out after bronchography or instead of it in doubtful cases for the final determination of 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 sizes 3-8 cm;
The contours of the shadow are fuzzy;
The intensity is average;
The structure is homogeneous;
In the root on the side of the lesion, enlarged lymph nodes are visible due to hyperplasia, the root is non-structural due to fiber infiltration.
X-ray signs opened abscess:
Symptom of "annular 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 enlightenment, since the opening of the abscess often occurs in the bronchus, and below
(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;
When bronchography, contrast enters into the abscess cavity, the surrounding bronchi are deformed up to 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 an acute course, after 2 weeks, the size of the shadow decreases, the wall of the cavity becomes thinner, 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 infection occurs, 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 in a conventional X-ray examination?
Answer. N.E. Stern and V.N. Stern - doctors of medical sciences, heads of the radiology department of the 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 soaking with lime salts. Complications of the cyst:
In the pleura with the formation of hydropneumothorax (rarely),
In the bronchus (often) with secondary seeding,
In the lungs (bronchogenic seeding),
In vessels with hematogenous seeding in the liver, bones, kidneys, etc.;
In the x-ray picture, two phases of development of an echinococcal cyst of the lungs, which, on conventional x-ray examination, are manifested by the following signs.
The phase of an unopened cyst, completely filled with fluid. X-ray semiotics:
Symptom of "round shadow", which is actually always oval;
The shape of the shadow changes with deep breathing, which indicates liquid content;
Single or multiple (in the amount of 2-3), in the latter case, unilateral or bilateral lesion;
The contours are clear, even or uneven due to diverticulum-like protrusions and notches;
Sizes from 1 to 20 cm;
The structure is homogeneous;
The intensity is average;
Around the shadow, a rim of enlightenment is determined due to the pushing of the surrounding tissues;
The growth of the cyst is slow, but spasmodic.
With a small amount of air in the pericystic gap, cyst rupture, while on the periphery of the shadow of the cyst
(between the fibrous capsule and the chitinous membrane) bubbles or strips of enlightenment (air) are detected. Clinically, the anguish does not manifest itself and the only diagnostic method is x-ray. Before the onset of the next stage - rupture of the cyst, an operation (removal of the cyst) is necessary so that seeding does not occur.
In the process of further accumulation of air in the pericystic gap, a symptom occurs "crescent enlightenment" at the superior pole of the cyst. It's already a sign rupture of the cyst. Then suddenly there is a cough with 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, crescent-shaped enlightenment 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 dropouts in the surrounding tissue.
Then, with an even greater accumulation of air in the pericystic gap, the so-called symptom is visualized. "double arches" 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 also 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 position of the body changes (symptom of "kaleidoscope").
Question 13. What are the tomographic and bronchographic signs of an echinococcal cyst and in what phase of development can they be detected?
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.
ruzhivayut both in the phase of the unopened and in the phase of the opened cyst.
Leakage of contrast from the bronchi into the pericystic gap bronchography in the phase of an unopened cyst is a pathognomonic sign of echinococcus.
Admission through the bronchi into the cavity of the cyst contrast with bronchography in the phase of the opened cyst, while against the background of a high-contrast substance in the cavity, wrinkled chitinous shell in the form of irregularly shaped filling defects.
Question 14. What is a hamartoma? What are its radiographic features?
Answer.Hamartoma - a benign tumor most commonly seen in the lungs.
X-ray signs of hamartoma:
Symptom of "round shadow";
The shape of the shadow is round, oval or pear-shaped;
Sizes up to 5 cm;
Contours are clear and even;
Against the background of the shadow (in the center), large clumps of lime are visible;
There is no decay in the tumor;
Around the shadow there is a rim of enlightenment due to the pushing of neighboring tissues;
The bronchi are not changed;
Growth is slow.
Question 15. From what elements of the lungs does central cancer originate? 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 originates from the large bronchi
Main;
Equity;
Segmental.
Varieties 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:
Darkening hemispherical shape;
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 darkening of the entire lung, lobe or segment of high intensity;
Its structure is homogeneous;
Interlobar fissures and mediastinum are displaced towards the lesion due to a decrease in the volume of the corresponding section of the lung;
On tomograms and bronchograms - the stump of the bronchus due to its obstruction by the tumor.
peribronchial or branched cancer spreads along the wall of the bronchus. Radiologically determined:
The main pathological symptom on plain radiographs is a diffuse enhancement of the lung pattern with a fan-shaped departure of linear shadows from the root into the lung tissue;
Thickening of the walls of the bronchi over a large extent, which can be seen on tomograms;
Frequent association with exobronchial cancer.
Question 16. From what anatomical structures of the lungs does peripheral cancer originate and how does it manifest itself radiologically? 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 and more.
The shape of the shadow is irregularly rounded, stellate, amoeboid or in the form of dumbbells.
The contours are uneven, bumpy, fuzzy, their radiance is characteristic.
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, as it were, of several merged round shadows.
Decay, which happens often, then the shadow becomes annular, while a decay cavity appears, its characteristic:
The location is eccentric, less often - central;
The shape is wrong;
The walls of the cavity are uneven, thick;
There is no liquid in the cavity or its amount is small;
The inner contour of the wall is clear;
There may be partitions in the cavity.
Small-lump calcification (rare).
The interlobar fissure adjacent to the tumor is either retracted or bulging.
Question 17. What can complicate lung cancer, regardless of the nature of its growth?
Answer. Lung cancer, regardless of the nature of its growth, can have the following complications.
Violation of bronchial patency of varying degrees due to compression or germination of the main, lobar or segmental bronchi with the formation of phenomena in the lungs:
Hypoventilation (with incomplete bronchial obturation);
Atelectasis (with complete obturation).
Disintegration in the tumor (eccentric or central in the cavity form of peripheral cancer).
Pneumonia, which is called paracancrotic or pneumonitis.
Pleurisy, the causes of which may be:
Compression of the lymphatic vessels;
blockage of lymph nodes;
Metastases in the pleura.
Metastases in the lymph nodes of the root.
Metastases in the lymph nodes of the mediastinum.
Sprouting by a tumor of neighboring organs and tissues:
mediastinum;
chest wall.
Distant metastases are most often:
in the liver;
In the brain;
Into the bones.
Question 18. In what 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 radiographically as described below.
IN root lymph nodes:
Root growth;
The appearance of round shadows in the corresponding root;
No loss of root structure, as there is no infiltration.
IN mediastinal lymph nodes:
Expansion of the shadow of the mediastinum mainly in the upper and middle sections;
Waviness and polycyclicity of the external 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, at the same time, germination, and not metastasis, is possible, which happens mainly with peripheral cancer. On the radiograph, this is manifested by the absence of a 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 seeding 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 the fluid is oblique, located within the sinus (rib-diaphragmatic) and above, up to the total darkening of the entire lung field, which depends on the amount of fluid;
The lower border of the dimming always merges with the aperture;
The dimming has a uniform structure;
The dimming intensity is high;
The mediastinum to some extent is displaced in the opposite direction.
Question 19. What is the algorithm of X-ray methods aimed at detecting lung cancer, clarifying the nature of its growth and prevalence? What is the need to use each of the methods?
Answer. The algorithm of X-ray methods aimed at detecting lung cancer, clarifying the nature of its growth and prevalence seems to be as follows.
To detect lung cancer at an early stage, fluorography, which is carried out annually, starting from the age of 15, special attention is paid to high-risk groups, where the following factors matter:
Heredity;
Smoking;
Repeated unilateral pneumonia;
Hemoptysis, etc.
After identifying signs on fluorograms that are suspicious of lung cancer, it is necessary to survey radiographs in direct and lateral projections, which allow you to identify:
Hypoventilation or atelectasis;
Shadow in the root or parenchyma of the lung;
Expansion of the roots and mediastinum;
Rib destruction, etc.
X-ray.
Clarification of tumor localization due to polypositional examination.
Identification of functional symptoms.
Identification of fluid in cavities (by its movement).
Determination of the mobility of the diaphragm (its immobility is noted during compression or germination of the phrenic nerve).
Conducting 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:
contours;
Structures, including with the identification and establishment of the nature of the decay.
The state of the surrounding tissues.
Metastasis to the lymph nodes of the root and mediastinum.
Bronchial condition:
Bronchial stump in endobronchial cancer;
Narrowing of the bronchus in exobronchial and peripheral cancer;
Multiple constrictions 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.
Check for cancer.
Differential diagnosis is carried out with liquid volumetric formations by density using the Hounsfield scale:
With an abscess;
With cysts;
Determine the direction of tumor growth.
Metastasis is detected in the lymph nodes of the root and mediastinum.
Germination of ribs and pleura is determined.
Distant metastases are detected (in 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 of the following localizations metastasize to the lungs:
mammary gland;
Stomach
Intestines;
prostate, etc.
Metastases in the lungs can be combined with other metastases of the chest cavity:
In the lymph nodes of the root;
In the lymph nodes of the mediastinum;
In the ribs;
In the vertebrae.
X-ray manifestations of metastases in the lungs.
Miliary metastases(multiple, bilateral), radiographically look like:
In the form of focal shadows;
The contours are clear and even;
The centers do not merge;
The number of shadows increases towards the diaphragm, and the tops of the lungs are not affected (unlike tuberculosis);
Metastases in the form of round shadows:
Single or multiple;
One-sided or two-sided;
Shadow sizes up to 1-2 cm;
The contours are clear and even;
The structure is homogeneous;
Interstitial metastases(crawl along the bronchi).
Diffuse enhancement of the lung 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:
Surgery for cancer in history;
The 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. On radiographs and tomograms of the chest organs of patient T., 67 years old, multiple bilateral round shadows are revealed, the number of which increases towards the diaphragm, their contours are even, up to 1 cm in diameter, do not merge, the structure is homogeneous. The roots on both sides are enlarged 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. On radiographs and tomograms of the organs of the chest cavity of patient Z., 48 years old, atelectasis of the middle lobe was found in the form of a darkening of an inhomogeneous structure. In adjacent segments, a reinforced and deformed pulmonary pattern is visible. On the bronchograms on the right, the bronchi of the S IV-V segments are contrasted throughout, they are brought together, shortened, and look like a "beaded cord".
What should be the conclusion of the above picture?
Task 4. X-rays of the thoracic organs in a 25-year-old female patient Zh. show pathological symptoms that lead to a suspicion of enlargement of the 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 the patient L., 44 years old, total darkening is determined on the right, which has a high intensity, a homogeneous structure, the mediastinal shadow is shifted to the left.
What do you think is the reason for this picture?
Task 6. In patient A., 24 years old, an x-ray examination of the chest organs in the left pleural cavity revealed liquid in the form of a high-intensity homogeneous blackout, the lower contour of which merges with the diaphragm, the mediastinum is displaced in the opposite direction.
In what cases will the upper boundary of the liquid have an oblique level, and in which cases it will have a horizontal level?
Task 7. X-ray of the chest cavity organs in patient D., 36 years old, on the right side, a rounded shadow, of medium intensity, heterogeneous structure, up to 2 cm in diameter, its contours are clear, but uneven. The connection of the shadow with the tail part of the root is noted. There is a suspicion about the vascular nature of this formation (angioma).
Assign a method of X-ray examination, which will help to give the correct conclusion based on the received additional symptoms (what?).
Task 8. On radiographs of the chest cavity organs in direct and lateral projections of the patient U., 69 years old, a pathological shadow of a hemispherical shape with an external uneven radiant contour is determined in the right root. On additionally produced tomograms, it can be seen that the bronchi passing through the shadow are not changed.
What causes the shadow in the root: central exobronchial cancer or enlarged lymph nodes?
Task 9. During the initial X-ray examination of the patient D., 57 years old, in the left lung in S VI, a symptom of a “round shadow”, up to 5 cm in diameter, is found, the contours are fuzzy. It gives the impression of a peripheral cancer complicated by paracancrotic pneumonia, as there are clinical signs of inflammation (fever, cough, leukocytosis). After anti-inflammatory therapy, after 1 week, during the control radiography, the round shadow turned into an annular one, i.e. disintegration occurred in the form of a cavity of enlightenment, which has a central location, the walls of the cavity are uneven, fuzzy, the cavity contains a large amount of fluid, on the tomograms, the tuberosity of the contours and partitions in the cavity is not determined.
Did the nature of the decay change your initial impression of the pathological process?
Task 10. Patient M., 43 years old, who came from a village where he has his own farm (dogs, chickens, a cow, etc.), had x-rays of the chest cavity organs in two projections due to subfebrile temperature and cough. On the right in S VIII, an annular shadow of an oval shape, 3x4.5 cm in size, was found, the contours are clear, even, the wall of the cavity is thin, uniform, contains a horizontal level of fluid, under which an additional shadow of irregular shape is determined, moving with a change in body position.
Conclusion: opened abscess.
Do you agree with the conclusion?
SUMMARY TOPICS FOR INDEPENDENT WORK,
NIRS AND WIRS
1. Varieties of anomalies in the development of the lungs and their radiographic manifestations.
2. Features of X-ray diagnostics of acute pneumonia in children.
3. Shadow picture in various forms of acute pneumonia in adults, the algorithm for using radiation methods and techniques and their information content in detecting pathological changes.
4. Features of the X-ray picture in various phases of the development of an echinococcal cyst of the lung.
5. X-ray diagnosis of destructive pneumonia in children.
6. Some diagnostic aspects in radiographic detection of abscess and abscessing pneumonia.
7. Computed and X-ray tomography in the diagnosis of central lung cancer and its regional metastases.
8. Differential radiodiagnosis of round shadows in the lungs.
9. X-ray manifestations of chronic pneumonia.
10. Radiation diagnostics in the detection and assessment of the nature of intrabronchial and extrabronchial benign tumors.
11. Differential X-ray diagnostics of pulmonary disseminations.
12. Fluorography and tomography in the evaluation of various forms of pulmonary tuberculosis.
13. Informativity of radiation methods in the diagnosis of tumors and cysts of the mediastinum.
14. X-ray diagnostics of diseases of the pleura.
SCHEME OF DESCRIPTION OF RADIOGRAMS AND FLUOROSCOPIES OF THE ORGANS OF THE CHEST CAVITY
I. Name and age of the patient.
II. General assessment of the radiograph.
Methodology.
X-ray.
Radiography:
Plain radiograph;
Target radiograph;
Superexposed radiograph.
Tomogram.
Bronchogram.
Computed tomogram.
Angiogram.
Indication of the studied organs (organs of the chest cavity).
Research projection:
Lateral;
Lateroposition.
Image quality:
Contrast;
sharpness;
Rigidity of beams;
Correct installation, etc.
III. The study of the lungs.
Determining the shape of the chest:
Plain;
in the shape of a bell
Barrel-shaped, etc.
Estimation of lung volume:
Not changed;
The lung or part of it is enlarged;
Reduced.
Establishment of the state of the lung fields:
transparent;
Blackout;
Enlightenment.
Analysis of the lung pattern:
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 segments.
Dimensions in centimeters (at least two sizes are indicated).
rounded;
oval;
Wrong;
triangular, etc.
Contours:
Smooth or uneven;
Clear or fuzzy.
Intensity:
Medium;
high;
lime density;
metallic density.
Shadow structure:
Homogeneous;
Heterogeneous due to decay or lime inclusions, etc.
Functional signs on fluoroscopy:
Changes in the shape of a round shadow during breathing - with liquid formations (cysts);
Shadow pulsation in vascular formations (aneurysms, angiomas), etc.
Correlation of pathological changes with surrounding tissues:
Strengthening of the lung pattern in the surrounding tissues;
The rim of enlightenment around the round shadow due to the pushing away of neighboring tissues;
Pushing or pushing apart the bronchi or blood vessels, etc.
Screening centers, etc.
IV. The study of the organs of the mediastinum.
Location:
Not displaced;
Displaced (towards pathological changes in the lungs or in the opposite direction).
Dimensions:
not enlarged;
Expanded 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, then this may be due to volumetric formations of the heart, blood vessels, lymph nodes, etc.
Contours:
Uneven.
Functional state during fluoroscopy:
The rhythm of heart contractions;
Jerky displacement of the mediastinum during exhalation towards atelectasis, etc.
v. Examination of the walls of the chest cavity.
Condition of the sinuses of the pleura:
Free;
They have pleurodiaphragmatic adhesions.
Soft tissue condition:
not changed;
Increased;
There is subcutaneous emphysema;
Foreign bodies, etc.
Condition of the skeleton of the chest and shoulder girdle:
The location of the bones;
Their form;
contours;
Structure;
The presence of fused or non-fused fractures.
Diaphragm condition:
The location is common;
Displacement proximally by one intercostal space, etc.;
The domes have even contours or are deformed by pleurodiaphragmatic adhesions;
Diaphragm movement during fluoroscopy.
VI. Conclusion about the state of the chest cavity.
In the absence of pathological changes, one can confine oneself to a descriptive picture without a conclusion.
Superexposed 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, etc.
You can use an alternative option in cases that are difficult to diagnose. It should be noted that when any pathological
logical syndrome in the lungs, pleura, mediastinum, chest, it is always described in the first place, and then the state of the surrounding tissues is described according to the above scheme.
SAMPLE PROTOCOLS FOR THE DESCRIPTION OF SOME RADIOGRAMS OF THE ORGANS OF THE CHEST CAVITY
Protocol? 21
Patient Sh., 15 years old. X-ray of the organs of the chest cavity in direct projection(Fig. 3.1).
The right lung is in a collapsed state (about 1/3 of its volume), the left lung is in an expanded state. On both sides, there is a diffuse enhancement of the pulmonary pattern and its deformation mainly according to the cellular type. The roots of the lungs are fibrotized. Sinuses of the pleura are free. The shadow of the mediastinum 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 rupture of the alveoli 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 direct projection; d - radiograph of the organs of the chest cavity in the right lateral projection
structures, against its background, light stripes of the bronchi are visible (in the medial sections). The right root is expanded, not structural. In other departments on the right and on the left, the lung fields are transparent, the lung pattern is not changed, the left root is not expanded, structural. The shadow of the mediastinum is not displaced, not expanded, the aorta has the usual location and diameter. Sinuses of the pleura are free. The diaphragm is located at the level of the VI rib, its shape is domed.
Conclusion: right-sided lower lobe parenchymal pneumonia.
X-ray of the chest organs in a straight line(Fig. 3.2 c) and right lateral projection(Fig. 3.2 d) after 10 days.
The darkening described earlier is not defined. Lung fields are transparent. The lung pattern is not changed. The roots of the lungs are not expanded, structural. The shadow of the mediastinum of the usual location, size and configuration. Sinuses of the pleura are free. The diaphragm, bone skeleton and soft tissues are not changed.
Conclusion: the disappearance of the above 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-ray of the chest organs in a 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, blackouts of medium intensity, heterogeneous structure are found, light stripes of the bronchi are visible against its background, the volume of the affected segments is not changed. Both roots are enlarged, not structural, enlarged lymph nodes are visible in them. In other departments on the right and left lung fields are transparent, lung pattern is not changed. The shadow of the mediastinum is not displaced, somewhat dilated due to the left ventricle of the heart, the aorta has the usual location and diameter, and is compacted. Sinuses of the pleura are free. The diaphragm is located at the level of the VI rib, its shape is domed.
Conclusion: bilateral parenchymal pneumonia mainly in the reed segments, age-related changes in the heart and aorta.
Radiographs of the organs of the chest cavity in the direct, right and left lateral projections after 10 days.
Rice. 3.3. Patient D., 58 years old. Bilateral parenchymal pneumonia, mainly in the reed segments, age-related changes in the heart and aorta:
a - X-ray of the organs of the chest cavity in direct projection; b - radiograph of the organs of the chest cavity in the right lateral projection; c - X-ray of the chest cavity in the left lateral projection. Spiral computed tomography after 10 days (d) - confirmation of the radiological conclusion, data for the presence of a malignant nature of the pathological process was not received
X-ray picture of the above 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 fully correspond to the X-ray data. On both sides, more on the left, in S IV-V, infiltrative changes of medium density, heterogeneous structure are found, against their background, unchanged bronchial lumens are visible, the volume of the affected segments is not changed. Both roots are enlarged, not structural, enlarged lymph nodes are visible in them. In other departments on the right and left pathological changes in the lungs are not visualized. The shadow of the mediastinum is not displaced, somewhat dilated due to the left ventricle of the heart, the aorta has the usual location and diameter, and is compacted. In the pleural cavity, the fluid is not determined. The diaphragm is located at the level of the VI rib, its shape is domed.
Conclusion: bilateral parenchymal pneumonia mainly in the reed segments, the transition to a protracted course. Age-related changes in the heart and aorta. Data for the malignant nature of the pathological process has not been received.
Protocol? 24
Patient B., 66 years old (Fig. 3.4).
X-ray of the chest organs in a 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, there is a weakly intense darkening, against which an enhanced, contiguous and deformed pulmonary pattern of uneven diameter is visualized. On the rest of the left, as well as in the right lung, the lung fields are transparent, the lung pattern is not changed. The roots are not expanded, structural. The shadow of the mediastinum 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 is recommended in frontal and left lateral projections.
X-ray tomograms in frontal and left lateral projections.
On tomograms, the darkening of S VII-IX-X on the left looks heterogeneous, the lumen of the bronchi is not visualized, so 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 X-ray: a - X-ray of the chest cavity in direct projection; b - radiograph of the organs of the chest cavity in the left lateral projection. Establishment of fibroatelectasis and mixed bronchiectasis in S VIII-IX-X during bronchography: c - bronchogram in direct projection; d - bronchogram in the left lateral projection
Bronchograms of the left lung in a straight line(Fig. 3.4 c) and left side(Fig. 3.4 d) projections.
On the left, convergence and shortening of the bronchi S VII-IX-X is revealed, their uneven expansion along the 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-ray of the chest organs in a straight line(Fig. 3.5 a) and right side projections.
On the right, the upper lobe is darkened, reduced in size. Darkening is intense, increases towards the root, uniform. The left lung field is transparent, the lung pattern is normal. The right root is pulled up, its shadow merges with the darkening described above, the left root is not changed. 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: 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 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 is found on the right, which indicates obstructive atelectasis. Enlarged lymph nodes are determined in the right root.
Conclusion: central, predominantly endobronchial, cancer of the right upper lobe bronchus, complicated by lobe atelectasis and metastases to the lymph nodes of the right root.
X-ray of the chest organs in a straight line(Fig. 3.5 d) and right lateral projections after 2 months(after chemotherapy).
There is an almost complete disappearance of atelectasis with the expansion of the upper lobe of the right lung. Lymph nodes of the right root decreased somewhat.
Radiographs of the organs of the chest cavity in the direct and right lateral projections. X-ray tomograms in direct projection 9.5 cm from the back (Fig. 3.5 e) and in the right lateral projection 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 X-ray (a - X-ray of the chest cavity in 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 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, a decrease in the lymph nodes of the right root (d - X-ray of the chest cavity in direct projection). After 1 month from the previous X-ray examination - the progression of the process: total atelectasis of the right lung, the stump of the right main bronchus is visible (d - X-ray tomogram in 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-ray of the chest organs in a straight line(Fig. 3.6 a) and left side(Fig. 3.6 b) projections.
On the left in S IV, a rounded ring-shaped shadow, 5 cm in diameter, with fuzzy outer and inner contours, is found. The wall of the cavity of uneven thickness (from 0.5 to 1.0 cm) due to the sequester along the upper wall contains a horizontal level of liquid, which occupies 2/3 of the volume. In the circumference of the cavity, there is an increase, fuzziness and deformation of the pulmonary pattern. The left root is expanded,
Rice. 3.6. Patient M., 37 years old. Radiographs of the organs of the chest cavity in direct (a) and left lateral (b) projections. Abscess of the left lung in S IV.
unstructural. The right lung field is transparent, lung pattern and root are not changed. The shadow of the mediastinum is not displaced, the usual size and configuration. Sinuses of the pleura are free. The diaphragm is located at the level of the VI rib, its shape is domed.
Conclusion: abscess of the left lung in S IV . Dynamic control in the course of treatment is necessary.
Protocol? 27
Patient S., 18 years old. X-ray of the chest organs in a straight line(Fig. 3.7) projections.
On the right in S III, an annular shadow of a rounded shape, 6 cm in diameter, with thin, 0.1 cm thick, even, uniform walls, clear outer and inner contours, is found. 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 organs of the chest cavity in direct projection. Solitary air cyst of the left lung in S TTT
Protocol? 28
Patient M., 9 years old. X-ray of the organs of the chest cavity in a straight line(Fig. 3.8) projections.
On the left, occupying almost the entire lung field, an oval-shaped shadow is found, 15x4 cm in size with clear in places, in places indistinct contours of a homogeneous structure. In the circle of the shadow, a darkening of the average intensity of the inhomogeneous structure is noted, which merges 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 echinococcal cyst of the left lung, complicated by perifocal pneumonia
configuration. Sinuses of the pleura are free. The diaphragm is located at the level of the VI rib, its shape is domed.
Conclusion: unopened echinococcal cyst of the left lung, complicated by perifocal pneumonia.
Protocol? 29
Patient Z., 24 years old (Fig. 3.9).
X-ray of the chest organs in a 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, an impression of heterogeneity of the structure is created due to several centrally located large-block 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. 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 the pathological shadow with the presence in it of several centrally located large-lumpy calcifications is confirmed.
Conclusion:
Radiograph of the drug removed during surgery(Fig. 3.9 e).
The X-ray picture of the preparation 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 X-ray: a - X-ray of the chest cavity in direct projection; b - radiograph of the organs of the chest cavity in the left lateral projection. Hamartoma of the left lung in S III with calcification during tomography: c - X-ray tomogram of the chest cavity organs in 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 drug removed during the operation (e)
Protocol? thirty
Patient B., 61 years old.
Radiographs of the organs of the chest cavity in the 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. In the pleural cavity, the fluid is not determined. The diaphragm is located at the level of the VI rib, its shape is domed.
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 side (by 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, a hyperdense formation of an irregular shape, 3x4 cm in size, an inhomogeneous structure with tuberous and radiant contours, is found, there is an eccentrically located irregularly shaped hypodense focus, 1.5x2 cm in size, without a liquid level. An intimate connection of the posterior contour of the formation with the parietal pleura is noted, the latter is thickened in this zone, but there is no fluid in the pleura. Other departments of the right lung and the left lung were not changed. From the described formation to the right root there is a “path”, enlarged lymph nodes are visible at the root. No enlarged lymph nodes were found in the mediastinum, as well as other pathological changes.
Conclusion: peripheral cancer of the right lung in S, complicated by disintegration, germination 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.
Peripheral cancer of the left lung in S VI, complicated by decay, germination of the parietal pleura and metastases to the lymph nodes of the left root
Protocol? 32
Patient M., 56 years old (Fig. 3.12).
Radiographs of the organs of the chest cavity in a 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 bronchial obstruction on radiography:
a - X-ray of the organs of the chest cavity in direct projection; b - radiograph of the organs of the chest cavity in the left lateral projection. Central, predominantly exobronchial cancer of the left lung without impaired bronchial patency with metastases to the lymph nodes of the root during tomography: c - X-ray tomogram of the chest cavity organs in 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, a shadow of an irregular hemispherical shape, 4x6 cm in size, with uneven bumpy and radiant contours, is found. For the rest of the length, the left and right lungs are transparent, the pulmonary pattern is not changed. The left root merges with the darkening described above. 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. In the pleural cavity, the fluid is not determined. The diaphragm is located at the level of the VI rib, its shape is domed.
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 organs of the chest cavity in a straight line (at a depth of 9.5 cm, rice. 3.12 c) and left side (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, an increase in lymph nodes in the left root is 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 H., 32 years old (Fig. 3.13).
X-ray of the chest organs in a straight line(Fig. 3.13 a) and right side(Fig. 3.13 b) projections.
On the right, the lower half of the lung field is darkened. The darkening is intense, uniform, its lower border merges with the diaphragm, the upper one is concave, obliquely ascending from the anterior end of the III rib to the lateral surface of the I rib (Damuazo line). In the right lateral projection, it is noted that the darkening occupies the peripheral parts of the lung field. The left lung field is transparent, the lung pattern is not changed. Sinuses of the pleura are free. The shadow of the mediastinum is shifted to the left, the usual 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 domed.
Conclusion: right-sided exudative pleurisy.
Rice. 3.13. Patient H., 32 years old. Right-sided exudative pleurisy: a - X-ray of the chest cavity in direct projection; b - radiograph of the organs of the chest cavity in the left lateral projection
Protocol? 34
Patient M., 56 years old. X-ray of the chest organs in a straight line(Fig. 3.14) and left lateral projections.
On the left, a darkening of the lung field is found throughout. Darkening is intense, homogeneous, its lower border merges with the diaphragm, the upper one - with the apical pleura. The right lung field is transparent, the lung pattern is not changed. 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 domed.
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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