Introduction to Radiology

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Introduction to Radiology

• Michael Solle, MD, PhD

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Introduction to Radiology

• I Radiology Basics and High Yield Topics
• Modalities in Radiology and Cases
• Contrast
• How to look at studies
• Catheters tunneled vs non-tunneled
• Drains and Tubes
• II How to Consult Radiology
• III Plain Film Imaging of the Abdomen
• IV Parting Thoughts
• Dr. Molina and Chest Radiology

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Definition of Radiology

• Radiology is a medical specialty using medical
  imaging technologies to diagnose and treat
  patients.

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I Basics/Hi-YieldRadiology Modalities

• Conventional radiographs (x-rays)
• Fluoroscopy
• Mammography
• Computed Tomography (CT)
• Nuclear Medicine (NM)
• PET-CT combines CT and NM
• Ultrasound (US)
• Magnetic resonance imaging (MRI)

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Radiology Modalities

• Conventional Radiography
• Lingo
• Density
• Opacity
• Observable Densities
• Metal
• Bone
• Soft Tissue
• Gas

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Radiology Modalities

• Fluoroscopy
• Live imaging
• Contrast agents often given

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Radiology Modalities

• Computed Tomography
• Lingo
• Attenuation
• Density
• Enhancement
• Hounsfield Units
• -1000 air
• -100 fat
• 0 water
• 20-80 soft tissues
• 100s bone/Ca/contrast
• gt1000s metal
• Large radiation dose

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Radiology Modalities

• Nuclear Medicine
• Lingo
• Counts or Activity
• Physiologic imaging
• Radionuclides
• Technetium
• Radiopharmaceuticals
• Choletec
• Radioactivity stays with the patient until
  cleared or decayed

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Radiology Modalities

• Ultrasound
• Lingo
• Echogenicity
• Shadowing
• Doppler for flow
• No radiation
• Can be portable
• Relatively inexpensive

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Radiology Modalities

• MRI
• Lingo
• Signal intensity
• T1
• T2
• Enhancement
• No radiation
• Strong magnetic field
• No pacemakers
• No electronic implants
• Small, loud tube and patients must be able to
  hold still
• Relatively expensive

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Radiology Modalities

• Four different cases of Abdominal Pain
• Can you develop a differential diagnosis based
  location of the abdominal pain?
• Can you identify the modality used?
• Diagnosis?

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Case 1 RUQ pain
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Case 2 RUQ pain Diagnosis?
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Case 3 RLQ pain Diagnosis?
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Case 4 RLQ pain Diagnosis?
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I Radiology Modalities Summary

• Conventional radiographs (x-rays)
• Great place to start (cheap, fast, low
  radiation).
• Computed Tomography (CT)
• Diagnostic dilemmas (pricier, variable speed b/c
  of contrast).
• High radiation.
• Nuclear Medicine
• Physiological imaging, great for specific
  questions.
• Ultrasound (US)
• Relatively inexpensive, and no radiation.
• Highly dependent on patients body size and US
  operator.
• Magnetic resonance imaging (MRI)
• Relatively expensive, no radiation, not fast.
• Unmatched ability to contrast healthy tissue from
  disease.

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I Basics/Hi-YieldA few words on contrast

• CT contrast
• IV- contains Iodine which attenuates x-rays
• Contraindicated in renal failure (acute and
  chronic) b/c of risk of contrast induced
  nephropathy
• Allergy issues
• Power injected and causes vaso-vagal reactions
  (NPO)
• PO- contains dilute iodine or sometimes very
  dilute barium (flouro studies typically use
  barium)
• MRI contrast
• IV- contains gadolinium chelated to a carrier
  molecule acts as a paramagnetic molecule which
  increases signal on T1 images
• Contraindicated in renal failure (acute and
  particularly ESRD) b/c of risk of NSF

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I Basics/Hi-YieldA few words on contrast

• AVOIDING CONTRAST IN THE SETTING OF ACUTE RENAL
  FAILURE IS DIFFICULT for the radiologist, because
  the creatinine may be normal.
• In hyper-acute renal failure, the creatinine
  hasnt risen yet. Decreased urine output or
  anuria is acute renal failure regardless of the
  creatinine.
• Remember first do no harm! Non-contrast studies
  can often be quite helpful.

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I Basics/Hi-YieldLooking at Imaging Studies

• Adequate Study?
• Correctly labeled with patients name, MR, and
  the date of the study?
• Technically adequate?
• Systematic versus Focused look at a study
• Radiologist does both!
• As the requesting clinician, you should also look
  at your patients study (at least plain films),
  as well as follow up on the final report.
• PTX, PNA, pleural effusions, SBO, free air
• Evaluate lines and tubes (especially the ones you
  placed!)

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I Basics/Hi-YieldLooking at Imaging Studies

• PACS workstations (diagnostic versus clinical)
• Picture Archiving and Communications System
• Radiology, ER, ICUs, some surgery clinics
• Web based PACS (web 1000)
• WebCIS based PACS (java script)
• At UNC 6-PACS is PACS help desk

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I Basics/Hi-Yieldtunneled versus non-tunneled
catheters

• First, examine the patient!
• Inspect
• Palpate
• (Dont auscultate or percuss)
• A tunnel is a short (several inches) segment of
  catheter that is within the superficial soft
  tissues (subcutaneous fat) between the venotomy
  site and the catheter access site.
• Perm Caths
• PortaCaths
• Powerlines
• A tunnel or port pocket infection usually means
  removal of the line.
• CVAD central venous access device

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I Basics/Hi-Yieldtunneled versus non-tunneled
catheters
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I Basics/Hi-Yieldtubes drains (abscesses,
G-, Neph-)

• Most VIR drains/tubes need to be flushed with
  sterile saline.
• The purpose of this is simply to keep the tubes
  from getting clogged. All tubes should be
  flushed after use.
• Theres usually a 3-way stopcock to accomplish
  this.
• Nephrostomy and Gastrostomy tubes need to be
  changed every 3 months or so.
• Abscess drains usually need a sinogram (tube
  injection) to evaluate the cavity size and for
  any fistulous connections, about 2 weeks after
  placement.
• If cavity small and output of drain is low, then
  drain may be pulled. If its pulled too early,
  then the abscess will fester/return.
• Surgical drains are managed by the surgical
  teams, and often do not need to be flushed (no
  3-way stopcock).

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II Obtaining a Radiology Consult

• A Radiology consult is obtained every time a
  study is requested!
• Who handles these requests and reads these
  studies and/or performs these procedures?

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II Obtaining a Radiology Consult

• The Department of Radiology at the University of
  North Carolina at Chapel Hill has eight clinical
  sections
• Abdominal Imaging (Body CT, US, MRI, Flouro
  studies such as UGI and SBFT, Biopsies)
• Breast Imaging
• Cardiopulmonary Imaging (Chest, Cardiac)
• Musculoskeletal Imaging (Bone, ER RR, MSK MRIs)
• Neuroradiology (brain/spine CT MRI lumbar
  punctures)
• Nuclear Medicine (wide variety, PET-CT, bone
  scans, Cards)
• Pediatric Imaging (wide variety)
• Vascular-Interventional (wide variety)

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II Obtaining a Radiology Consult

• 6-1461- The Radiology Front Desk
• Reading rooms (RRs)
• Body CT 3-2938
• Chest 3-2939
• GI/Adult Flouroscopy 3-2961
• Neuroradiology 3-2978
• Pediatrics 6-7554
• MSK/bone 6-8850
• US 6-0038
• MRI 6-8112
• Mammography 6-6392
• Nuclear medicine 3-2937
• VIR 6-4645

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The Face of Radiology
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II Obtaining a Radiology Consult (at UNC
Hospitals)

• Try to call the right reading room (RR).
• When you call, identify yourself, and expect
  whoever answers to identify themselves.
• Improves accountability
• Good policy to know who you talked to (always)
• When paging, its nice to put your name/pager
  number immediately after the call back number
• After hours
• 6-8850 Lower Level/ER RR
• 216-2826 Upper Level (VIR, Doppler US, MRI)
• DONT call 6-8850 during the day
• unless its an MSK radiology issue

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II Obtaining a Radiology Consult

• VIR or any other invasive procedures
• Who gives consent? Pleae get phone number of HC
  POA or spouse or relative
• Basics for any invasive procedure
• See the patient!
• Coags (PT, PTT, INR)
• Platelets
• NPO for sedation or GA
• Dont promise the Bx/Line/procedure, but please
  tell the patient before we get there..
• Dont promise sedation (but we almost always use
  it)
• Think about risks/benefits prior to considering
  invasive or expensive procedures. Ask yourself
  if the results will change management.

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Please page us if our report is confusing!
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III Plain film imaging of the abdomen

• Stones
• Gallstones
• Renal stones
• Bones
• Lumbar spine, pelvis, hips
• Masses
• Organomegaly, ascites
• Gasses
• 3 cm small bowel
• 6 cm large bowel
• 9 cm cecum

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III Plain film imaging of the abdomen

• KUB (kidneys, ureters, bladder)
• 2 View---AP supine and erect abdomen
• Acute abdomen series 2 view with upright chest
• Lateral decubitus (Left or Right)
• Cross table lateral---prone or supine

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III Plain film imaging of the abdomen normal
supine KUB
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III Plain film imaging of the abdomen
Gallstones supine and erect
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III Plain film imaging of the abdomen
Gallstones
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III Plain film imaging of the Abdomen
Nephrolithiasis
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III Plain film imaging of the Abdomen
Nephrolithiasis
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III Plain film imaging of the Abdomen Bones
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III Plain film imaging of the abdomen ascites
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III Plain film imaging of the abdomen gasses?
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III Plain film imaging of the abdomen gasses?
This is SBO
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III Plain film imaging of the abdomen more gas
SBO easy to Dx
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III Plain film imaging of the abdomen more gas
SBO easy to Dx
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III Plain film imaging of the abdomen
Pneumoperitoneum
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III Plain film imaging of the abdomen
Pneumoperitoneum
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IV A Few Random Parting thoughts

• Patients want a doctor who cares about them.
  When admitting a patient, get their (familys)
  phone numbers yourself, as part of the History
  and Physical.
• Patients will forgive you for a host of small
  things if you show them that you care, will be
  honest with them, you will work hard for them
  over the long term.
• Getting their phone numbers show you care about
  them and their family.
• Learn to take ownership of your patients and
  their medical problems.
• Follow up on test/imaging results.
• Follow up on clinical outcomes.
• Longitudinal data is often the most valuable
  information there is.
• Old is gold.- in reference to getting prior
  imaging studies.
• Serial KUBs and serial exams is often more
  clinically relevant than getting a CT scan.

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Thanks for listening!