Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Important Topics Surgery X Rays
R.G.Kar Medical College
Created by
Prithwiraj Maiti
Email: prithwiraj2009@yahoo.in
References: M.L.SAHA
ADDITIONAL REFERENCE: SRB
EXPERT CONSULT INCLUDED
NOTE: Only the photo of sigmoid volvulus is not from
RGKMC. All other primary photos are taken from
surgery dept., rgkmc. FOR DESCRIPTION AND ILLUSTRATION
PURPOSE, THE SECONDARY PHOTOS ARE TAKEN FROM WEB
AND TEXTBOOKS, WHICH ARE SUBJECT TO COPYRIGHT TO THE
OWNERS.
TABLE OF CONTENT
SERIAL NO.
HEADING
PAGE NO.
1
FREE GAS UNDER DIAPHRAGM
2
2
T TUBE CHOLANGIOGRAM
7
3
INTESTINAL OBSTRUCTION
9
4
-DO-
13
5
SIGMOID VOLVULUS
14
6
IVU
19
SURGICAL IMAGING 1
Description:
It is a straight X-Ray of chest and abdomen showing free gas under both domes of
diaphragm.
What does it suggest?
Hollow viscus perforation.
What are the organs commonly perforated to produce such an appearance?
1. Peptic ulcer perforation: Gastric/ duodenal
2. Smal gut perforation: Typhoid ulcer/ tubercular ulcer/ Crohn's disease
3. Traumatic/ penetrating/ stab/ bullet injury
4. Appendicular perforation
5. Diverticular perforation
6. Following laparoscopic procedure/ abdominal operation.
Peptic perforation
How a patient of peptic perforation presents to the emergency?
Points
Findings
History
Acute onset of pain abdomen which starts in the
epigastric/RUQ region and later becomes generalized
There may be vomiting at the onset
Fever
There may be abdominal distension later on.
General survey
Features of shock:
Hypotension
Tachycardia
Dehydration.
Abdominal examination
Palpation
Restriction of movement of abdomen with respiration
Muscle guard/ rigidity all over the abdomen
In late stages, there may be abdominal distension
Tenderness over all quadrants of abdomen with
maximum tenderness over RUQ region.
Percussion
Liver dullness may be obliterated
Evidence of free fluid in abdomen.
Auscultation
Bowel sounds may be absent.
What is the line of treatment?
1. Exploratory laparotomy
2. Confirmation of diagnosis of peptic ulcer perforation
3. Simple closure of perforation with an omental patch (Graham's patch) by
interrupted polyglactin sutures
4. Thorough peritoneal lavage
5. Biopsy taking from ulcer margin to exclude malignancy.
Small gut perforation
What are the methods used for diagnosis of typhoid in different period of illness?
Period of illness
Method of choice
1st week
Blood culture
2nd week
Widal test
3rd week
Stool culture
4th week
Urine culture
What is the most common site of typhoid perforation?
Distal ileum.
What is the surgical treatment of choice in typhoid perforation?
As typhoid ulcers typical y involves Peyer's patches (which are numerous in
ileum), typhoid fever is notorious for causing multiple perforation and the
recurrence rate is very high. So, the surgical treatment of choice is:
If a single area of bowel is involved: Wedge excision of ulcer
If extensive area of bowel is involved: Segmental resection of bowel.
What is the most common site of tubercular ulcer perforation (Koch's
perforation)?
Ileo-caecal junction.
Appendicular perforation
Why free gas under diaphragm is less commonly found in appendicular
perforation?
Usually obstructive type of appendicitis leads to perforation.
The lumen of appendix contains very little amount of gas.
So, usually there is no free gas under diaphragm in case of appendicular
perforation.
Note: If the perforation involves base of the appendix, then there may be free gas
under diaphragm.
Mention the symptoms of acute appendicitis.
Pain
Vomiting
Fever
Together comprises "Murphy's triad".
Other features:
Constipation
Urinary frequency.
Signs of acute appendicitis
Blumberg's sign/ Release sign: Tenderness and rebound tenderness at McBurney's
point in right iliac fossa.
Rovsing's sign: On pressing over the left iliac fossa, pain occurs in right iliac fossa
which is due to shift of bowel loops which irritates the parietal peritoneum.
Cope's psoas test: Hyperextension of right hip causes pain in right iliac fossa due to
irritation of psoas muscle. It is positive in case of retrocaecal appendix only.
Obturator test: Internal rotation of right hip causes pain in right iliac fossa due to
irritation of obturator internus muscle.
Baldwing's test: When legs are lifted off the bed with knee extended, the patient
complains of pain while pressing over the flanks. It is positive in case of retrocaecal
appendix only.
Describe the pain in acute appendicitis?
RIF fossa pain (irritation
Pain eventually becomes
Peri-umbilical region
of parietal peritoneum
severe and diffuse
pain (due to distension of
due to inflamed
(spread of infection into
appendix)
appendix)
general peritoneal cavity)
Traumatic perforation
What is the commonest site of perforation caused by blunt trauma?
1. Duodeno-jejunal junction (commonest)
2. Recto-sigmoid junction.
Diverticular perforation
What history you may get in case of a diverticular perforation?
NSAID intake (it is a consistent risk factor of diverticular perforation).
Try yourself
SURGICAL IMAGING 2
Description:
This is one of the skiagram taken from a T-tube cholangiogram series showing
patency of the tube. There is no filling defect in the lumen of bile duct. The dye
has reached the duodenum, suggesting no obstruction in the terminal bile duct.
How a stone appears in a T-tube cholangiogram?
Radio-opaque shadow.
Some commonly asked questions about T-tube cholangiogram
Timing:
8th-10th postoperative day.
Contrast material:
Urograffin (60%)
Amount of contrast injected:
2-3 mL: Before 1st X-Ray is taken
4-5 mL: Before 2nd X-Ray is taken.
Indications:
Patient's with possibility of residual small gallstones after cholecystectomy
Obstructive jaundice
Bile duct stricture
Surgeon unable to explore bile duct during cholecystectomy surgery.
Contraindications:
Contrast/ iodine allergy
Pregnancy
Barium study within last 3 days.
Name some methods to remove retained CBD stones?
1. ERCP and stone removal in 3 weeks
2. Flushing of heparinized saline/ bile acid through the T-tube
3. Burhenne technique: After 6 weeks once T-tube track gets matured; using
Dormia basket/ choledochoscope, stone is removed through T-tube track
under fluoroscopic guidance.
4. ESWL with endoscopic sphincterotomy/extraction/ lavage/stenting
5. Through percutaneous transhepatic route, cholangioscope is passed and
CBD is visualised, stone is identified and removed using Dormia basket.
If the retained stone is detected after removal of T tube, how will you manage the
patient?
Endoscopic sphincterotomy and stone extraction by a Dormia basket catheter
introduced through the endoscope.
For more questions, please see description of the instrument `Kehr's T tube'.
SURGICAL IMAGING 3
Description:
This is a straight X-Ray of abdomen with lower part of chest and majority of
the pelvis taken in erect posture showing multiple air-fluid levels.
The left lumbar region is showing dilated bowel loops with prominent
valvulae conniventes (white lines between bowel loops); suggesting these
to be jejunal loops.
The right iliac fossa region is showing bowel loops with no valvulae
conniventes; suggesting these to be ileal loops.
How can you differentiate among a jejunal, ileal and a colonic gas shadow?
Jejunal gas shadow: Numerous and prominent valvulae conniventes
Ileal gas shadow: Sparse and less prominent valvulae conniventes
Colonic gas shadow: Presence of haustrations.
Note that:
o Valvulae conniventes: White line between bowel loops (as seen in X-Ray).
These are thin, circular, folds of mucosa, some of which are
circumferential and are seen on an X-ray to pass across the full width of
the lumen.
o Haustrations: The longitudinal muscles (taenia coli) and circular muscles
of the colon form sacculations called haustra, which have characteristic
radiographic appearance.
What features will the patient present with?
1. Colicky abdominal pain
2. Vomiting
3. Absolute constipation
4. Abdominal distension.
How will you manage this patient?
Perform an emergency laparotomy
Diagnose the cause of obstruction
Decompress the distended bowel loop
Assess the viability of gut
If gangrenous bowel: perform resection and anastomosis.
What is the commonest cause of small bowel obstruction?
Postoperative adhesions and bands formation.
What are the other causes if small bowel obstruction?
Causes in the wall of intestine:
Stricture caused by:
Benign: IBD, TB, Trauma, Ischemia, Radiation, Intussusception etc.
Malignant: Tumors in the intestine.
Causes in the lumen of intestine:
Gall stones
Foreign body
Worm.
Causes outside the wall of intestine:
Postoperative adhesions and bands
Hernia
Volvulus
Intussusception
Infiltration by a tumor.
Some basic concepts
Dynamic intestinal obstruction:
When there is mechanical obstruction of a segment of gut, the proximal
segment tries to overcome the obstruction by vigorous peristalsis.
Adynamic intestinal obstruction (Paralytic ileus):
In this case, peristalsis is absent; resulting in non-propulsion of gut contents.
Strangulated obstruction:
Intestinal obstruction with compromise in blood supply to the gut results in
strangulating obstruction.
While doing exploratory laparotomy, how will you differentiate between a viable
and a non-viable bowel segment?
The segment of confusion is covered with a hot moist pack.
Anaesthetist is asked to give the patient 100% oxygen for 10 minutes.
The gut is reviewed.
If the color of the segment becomes pink, peristalsis and arterial pulsation
returns, then the segment is viable.
SURGICAL IMAGING 4
Description:
This is a straight X-Ray showing lower part of chest, abdomen and upper
part of pelvis.
There are multiple air-fluid levels (white arrows), suggesting bowel
obstruction.
There are prominent valvulae conniventes (yellow arrows), suggesting that
the bowel loops involved are probably jejunum.
However, in right iliac fossa, valvulae conniventes are sparse, suggesting
that this part is showing ileal loops.
SURGICAL IMAGING 5
Description:
This is a straight X-Ray abdomen along with a part of pelvis taken in erect
posture.
There is a distended loop.
The right sided compartment of the loop is showing prominent
haustrations.
But the left sided part of the compartment is not showing any haustrations.
Left sided compartment of the loop is distended hugely and has extended
from pelvis to RUQ region.
- This is cal ed `omega sign appearance'.
There is a central double wall (arrows) between the right and left
compartments. A single wall forms the outer margin of the compartments.
- This is cal ed `coffee bean appearance'.
This appearance is suggestive of large bowel obstruction due to sigmoid volvulus.
What is volvulus?
Volvulus is an abnormal rotation of a segment of bowel around its narrow
mesentery.
What is danger of a volvulus?
It may lead to strangulation/ gangrene of
the involved bowel segment.
How much rotation is required for luminal
obstruction and vascular compromise?
180 and 360, respectively.
Do you know the direction of rotation?
Yes, rotation always occurs in anti-clockwise
direction.
What are the common sites of volvulus?
1. Sigmoid colon (commonest site)
2. Cecum
3. Transverse colon
4. Small intestine
5. Stomach.
What will be the presentation of the patient?
Abdominal pain
Abdominal distension
Absolute constipation (also called obstipation).
What are the risk factors for development of a sigmoid volvulus?
Adhesions
Peridiverticulitis
Overloaded redundant pelvic colon
Long pelvic mesocolon
Narrow attachment of sigmoid mesocolon.
Mention the characteristics radiological signs of a sigmoid volvulus.
Diagnostic modality Radiological sign
Description
Omega () sign
Single, grossly distended loop of colon arising
out of the pelvis and extending towards the
diaphragm.
Plain X ray
Coffee-bean sign Dilated loop of sigmoid colon has a "coffee-
bean" shape and the wall between the two
volvulated loops of sigmoid (black arrow)
"points" towards the right upper quadrant.
There is a considerable amount of stool (white
arrow) in the colon from chronic constipation.
Barium study
Birds beak sign
Upper end of barium column tapers into the
spirally twisted distal sigmoid colon.
How will you manage this patient?
Do resuscitate the patient at the very beginning. Then continue as follows:
Patient without any sign of strangulation
Non-operative decompression by pushing any of the following beyond the point
of volvulus may be tried:
I. Rigid sigmoidoscope
II. Flexible sigmoidoscope
III. Soft rubber catheter.
Patient with sign(s) of strangulation [features of shock and peritonitis]
The management of choice is emergency laparotomy and derotation of
volvulus.
Procedures of choice:
Sigmoid colectomy and primary anastomosis
Hartmann's procedure
Paul-Mikulicz Operation.
Hartmann's procedure
Resection of the gangrenous sigmoid done; proximal cut is brought out as end-
colostomy: distal end closed (which is re-anastomosed at a later date).
Paul-Mikulicz Operation
Resection of the gangrenous sigmoid done; proximal cut is brought out as end
colostomy: distal end is brought out as mucus fistula, from the rectum (which is
re-anastomosed at a later date).
SURGICAL IMAGING 6
Description:
This is one of the skiagram from
intravenous urography (IVU) series
after injection of dye.
On left, there is normal excretion
of the contrast. The left kidney
outline and pelvi-calyceal system
seems to be normal. Left ureter is
outlined normally.
On right, there is no excretion of
contrast. There is a large calculus
(yellow arrow) obstructing the
right pelvi-ureteric junction (PUJ).
Right ureter is not seen.
So, it is a staghorn calculus
obstructing the right PUJ.
Name some contrast agents commonly used for IVU?
Ionic agent: Urograffin (Sodium diatrizoate)-> 76%
Non-ionic agent: Omnipaque.
What is hydronephrosis?
It is a condition characterized by aseptic dilation of collecting system of kidney
due to partial/ intermittent complete obstruction.
Do you know the grading of hydronephrosis?
Grade
Description
1
Minimal dilation with slight blunting of calyceal fornices
2
Enlargement and obvious blunting of calyceal fornices; but intruding
shadow of papillae seen
3
Rounding of the calyces with obliteration of the papilla shadow
4
Extreme ballooning of calyces
How will you manage a case of hydronephrosis due to PUJ obstruction?
If there is adequate renal function and reasonable thickness of functional renal
parenchyma, I will do Anderson-Hynes pyeloplasty.
Procedure in short:
Kidney is exposed through a standard lumbar incision
The upper 1/3rd of ureter and pelvis is dissected
The redundant renal pelvis and PUJ are excised
A new pelvis is created and the cut end of pelvis is anastomosed to the
ureter in the dependent position.
This post was last modified on 01 September 2021