X Rays

Interesting X-rays
in
General Surgery
Inter esting X-rays
Interesting
in
General Sur gery
Surgery
RP Gupta
FRCS, MCh, FRACS, FICS
FCCP, FACC, FACS, FICA, FICAS
Thoracic, Cardiovascular and General Surgeon

Shanti Mukand Hospital
(A Unit of Shri Mukandilal Memorial Foundation)
Karkardooma, Delhi, India
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Interesting X-rays in General Surgery
© 2010, Jaypee Brothers Medical Publishers (P) Ltd.
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted
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This book has been published in good faith that the material provided by author is original. Every effort is
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First Edition: 2010
ISBN 978-81-8448-920-0
Typeset at JPBMP typesetting unit

Printed at ....
To
My mentor
Dr KC Mahajan
and
My parents and family
Preface
I have great pleasure in presenting this collection of X-rays for students. This book
is no replacement for Textbook of Radiology but this is a collection of interesting
X-rays during my career of 50 years as a General Surgeon. I thought going through
these X-rays might help any postgraduate in General Surgery.
RP Gupta
Acknowledgments
Most of the X-rays are my own collection but I am highly indebted to Dr Sudarshan
Aggarwal and Dr Ajay Aggarwal of Diwan Chand X-ray Clinic and Dr SP Gupta of
North Delhi Nursing Home for their kind contribution of some X-rays.
Contents
1. Chest ................................................................................................................1
2. Abdomen ...................................................................................................... 57
3. Genitourinary ............................................................................................ 127
4. Hepatobiliary ............................................................................................. 157
5. Important X-rays of Head and Neck ....................................................... 179
6. Breast ......................................................................................................... 187
7. Bones ......................................................................................................... 201
8. Esophagus ................................................................................................. 211
9. Miscellaneous ........................................................................................... 231
Index ............................................................................................................ 251

Chest
2 INTERESTING X-RAYS IN GENERAL SURGERY
Fig. 1: PA view of chest X-ray, lateral view
Fig. 2: AP view of chest

CHEST 3
X-RAY CHEST
Normally in the X-ray department, PA view of chest is taken and the patient is in a
special posture with his/her wrists on the waist. This helps to pull scapulae out of lung
fields and clavicles are horizontal so that upper lobes can be clearly seen on a PA view
of chest X-ray and chest is brought close to the X-ray film.
At times, we have to take AP view of chest, i.e. when the patients are in ICU and
X-ray chest taken or a pregnant lady in her 8th or 9th month of pregnancy, when the
chest cannot be brought close to the film due to protuberant abdomen.
In this view you will see scapula covering the upper and mid lung field and the
clavicles are in an oblique position, which will come in view of interpreting upper lobe
disease carefully. Hence, it is the position of scapula and clavicles which will tell you
whether it is a PA view or AP view of chest.
X-ray chest reading should be done systematically
• See which view of chest it is
• See all the bones and count ribs on both sides. Then you have less chance of missing
any abnormality or disease of bones. If on cursory look you say bony cage is normal,
there is a very high chance that you will miss bony abnormalities. See all the vertebrae
carefully to see for bone density and any bony destruction or any paraspinal collection.
• See for domes of diaphragm and their position and continuity
• Any free gas under domes of diaphragm
• See for the heart shadow, CT ratio
• See for hilar shadows, any prominence or abnormality
• Mediastinal shadow of bronchus, aorta and esophagus
• Look at lung fields upper, middle and lower lung fields on both sides. Any abnormality
has to be clearly and carefully analyzed, solid, cystic or any intracavity lesion.
• Lung fields, see for radiolucency and compare this on both sides
• See the pleural cavity for any pneumothorax and fluid collection or
hydropneumothorax. See for any pleural thickening or any pleural masses.
B
Fig. 3: Chest X-ray in expiration:
(A) Chest X-ray in inspiration showing pneumonitis in left lung;
(B) Showing emphysema in left lung
Fig. 4: Congenital diaphragmatic hernia

CHEST 5
MEDIASTINAL STRUCTURES
Chronically dilated distorted esophagus is seen as a structure on right upper mediastinal
border and at times it may have a fluid level as seen in achalasia cardia of long standing
duration.
Aortic knuckle is seen on left side but in few cases it may be seen on right side. There
may be a left superior vena cava on left upper mediastinal border merging with cardiac
shadow. Right middle lobe lies close to right lower cardiac border. If right lower cardiac
border is not clear or hazy, one has to suspect right middle lobe disease. If left cardiac
border is not clear or hazy, suspect disease in lingula of left upper lobe.
See in retrocardiac area on left side. Left lower lobe collapse will cast a triangular
density in retrocardiac region, when eye moves down the thoracic vertebral bodies,
each body should look more lucent than the above until the diaphragm is reached.
If a foreign body is suspected in the air passage of children always take a PA view of
chest in inspiration and other in expiration. The expiration film will show increased
residual air and radiolucency in the portion of lung distal to foreign body.
CONGENITAL DIAPHRAGMATIC HERNIA

1. Presence of loops of intestine in the left pleural cavity
2. Shift of cardiac shadow to right side
Fig. 5: Fracture ribs with hemothorax
Fig. 6: PA view of pseudotumor or encysted Fig. 7: Lateral view of chest showing

effusions in fissures effusions in interlobar effusions
CHEST 7
FRACTURE RIBS
See carefully and one can see there are fractures of ribs on both sides of chest in the
posterior region. Six ribs on left side and 4 ribs on right side
Associated hemothorax is present in left pleural cavity.
PSEUDOTUMOR IN THE CHEST

1. Cystic swelling seen in the chest on right side lying in the region of fissure in the lung
(A,B).
2. There are collections of interlobar encysted effusion.
3. Cardiac shadow shows prominent pulmonary artery and is enlarged.
4. This is seen commonly in congestive heart failure
5. Called pseudo tumors as these are not true tumors but encysted collection of trapped
fluid in interlobar fissures.
6. These disappear as soon as congestive heart failure is relieved.
Fig. 8: Calcified mode in axilla on right side
B
Figs 9A and B: (A) Collapsed left lung; (B) Left lung expanded after bronchoscopic aspiration
CHEST 9
CALCIFIED NODE RIGHT AXILLA

A round calcified density is seen in the right axilla. This is a calcified lymph node
usually due to healed tubercular infection.
COLLAPSE LEFT LUNG

1. Whole of left pleural cavity is opaque
2. Cardiac shadow is shifted to the left side
3. After aspiration of the thick mucus plug, the lung is fully expanded and cardiac
shadow has returned to normal position.
Fig. 10: Coarctation of aorta with rib notching
Fig. 11: Rib notching seen in coarctation

CHEST 11
COARCTATION OF AORTA
X-ray Chest showing rib erosion in the lower margin of ribs due to prominent collaterals.
Fig. 12: Emphysematous bulla in right lung
Fig. 13: Pancoast tumor in right apex

CHEST 13
EMPHYSEMATOUS BULLA
• Large radiolucent shadow is seen in right upper lobe region
• It has concave border which shows that the bulla is compressing the rest of the lung.
• In pneumothorax, this lower margin is convex due to collapsed lung margin and not
concave.
PANCOAST TUMOR
• Haziness is right upper lobe of lung
• These tumors may involve ribs and clavicle adjacent to the tumor.
Fig. 14: Fracture ribs
Fig. 15: Foreign body metal buttons in bronchi Fig. 16: Lateral view showing buttons in
bronchi
CHEST 15
FRACTURE RIBS WITH SURGICAL EMPHYSEMA

Fracture of ribs on right side along with surgical emphysema on right side.
FOREIGN BODY IN THE LUNG

Radio opaque foreign body (Metalic buttons) are seen in both hilar region and the
lateral view confirm their presence in bronchi.
Fig. 17: Nail in right bronchus PA view
Fig. 18: Lateral view showing nail in bronchus

CHEST 17
FOREIGN BODY IN LUNG

On PA view, a nail is seen in the right hilum. On lateral view it is seen in the right
bronchus.
Fig. 19: Small pneumothorax in right base
Fig. 20: Pneumothorax in right side
Fig. 21: Pneumothorax in right chest with

convex border of collapsed lung
CHEST 19
Fig. 22: Massive pneumothorax in right chest
PNEUMOTHORAX
• On right side there is partially collapsed right lung with a peripheral zone of air
round it.
• Other X-ray shows moderate size pneumothorax.
• One X-ray shows massive pneumothorax on right side.
Fig. 23: Neurogenic tumor in left apex
Fig. 24: Bilateral pulmonary Koch’s Fig. 25: Miliary tuberculosis in both
lungs
CHEST 21
SHADOW LEFT UPPER LOBE

Homogeneous shadow in the left upper lobe with calcified lower edge. It is a solid
tumor in the posterior part of left pleural cavity.
It was a neurogenic tumor.
PULMONARY TUBERCULOSIS
Bilateral infiltration is seen in upper lobes. There is evidence of fibrosis on right side.
Some infiltration is seen in lower lobe on both sides.
In one picture, one can see miliary tuberculosis in both lung fields.
Fig. 26: Congenital emphysema of left lung
Fig. 27: Bronchogram showing fungal ball in old Koch’s cavity on left side
CHEST 23
CONGENITAL EMPHYSEMA OF LUNG

• Left lung is hyperlucent
• Shift of mediastinum to right side
This is due to congenital obstructive emphysema of the lung due to congenital
malformation.
TUBERCULAR CAVITY WITH A FUNGAL BALL

There is a cavity in the left upper lobe.
Inside the cavity is a rounded shadow due to a fungal ball – aspergiloma which is
commonly seen in old tubercular cavities.
Fig. 28: Complete thoracoplasty left chest
Fig. 29: Cervical rib with fracture ribs

CHEST 25
THORACOPLASTY
• All ribs are absent from the left side
• All ribs have been removed and the lung has been compressed to reduce space and
collapse the lung to prevent hemoptysis and help the tubercular infection to heal or
to obliterate the cavity after lung resection if the pleural cavity gets infected.
FRACTURE RIBS AND CERVICAL RIBS

1. See the X-ray carefully and you will see on both side presence of cervical ribs, left
ribs is bigger than the right
2. On both sides, there is fracture of 1st ribs. It is not common to have bilateral 1st ribs
fracture.
3. There is no pneumothorax on either side.
Fig. 30: Collapsed left lower lobe with air bronchogram
Fig. 31: Bronchogram showing fungal ball in left apex

CHEST 27
COLLAPSE LEFT LOWER LOBE

1. Air Bronchogram is seen on the left side upto division of main bronchus.
2. Distal to this there is collapse of left lower lobe and the shadow is lying behind the
heart shadow. It is usually seen as a triangular shadow behind the cardiac shadow.
3. Shift of cardiac shadow to left side due to collapse.
ASPERGILLOMA
1. Bronchogram showing cavity in LUL
2. Fungus ball in the tubercular cavity.
Fig. 32: Encysted effusion in fissure on right side
Fig. 33: Pockets of encysted effusions in Rh Baso + right parahilar regions

CHEST 29
PSEUDOTUMOR
1. Rounded shadow in the right lower lobe region in the line of the great fissure.
2. This is encysted effusion and one may see more than one encystment and there are
called pseudotumors as there are not solid tumors but pockets of encysted effusions.
3. Commonly seen in congestive heart failure patients and these disappear once the
failure settles down.
Fig. 34: Morgagni hernia
Fig. 35: Lateral view of anteriorly located Morgagni hernia
Fig. 36: Barium enemia showing presence of Morgagni hernia

CHEST 31
MORGAGNI HERNIA
1. In PA view, there is a rounded shadow in the lower zone next to cardiac shadow.
2. In lateral view it is situated anteriorly
3. On barium enema, one can see position of transverse colon located in the sac in the
region of the shadow seen in PA view, confirming it to be hiatus of Morgagni hernia.
Fig. 37: Congenital diaphragmatic hernia
Fig. 38: Left hydropneumothorax

CHEST 33
TRAUMATIC LEFT DIAPHRAGMATIC HERNIA

1. Intestine has entered the left chest
2. Collapse of the base of left lung
3. Displacement of the heart to the opposite side.
HYDROPNEUMOTHORAX
1. Postoperative collection of fluid in left chest after left pneumonectomy
2. Note that fundus bubble is up, showing that left diaphragm is pushed up.
3. Mild shift of heart shadow to right side
4. Postoperative pneumonectomy collection of fluid is to fill up the space. This should
not be aspirated unnecessarily.
Fig. 39: Pulmonary Koch
Fig. 40: Calcified aortic knuckle

CHEST 35
PULMONARY KOCH’S
Infiltration is seen in left upper lobe. Rest of the lung fields are normal.
CALCIFIED AORTIC KNUCKLE

In old age and atherosclerotic hypertensive patients, there is calcification in wall of
aortic arch which is dilated or prominent.
Fig. 41: Cylindrical bronchiectasis right lower lobe
Fig. 42: Retrosternal goiter

CHEST 37
BRONCHIECTASIS
1. Bronchogram of the right and left lungs showing cylindrical bronchiectasis in right
lower lobe
2. Normal bronchi of right upper lobe and left lower lobe.
RETROSTERNAL GOITER
• Globular shadow in the right upper mediastinum with normal lung undernealth.
Similar shadow is seen on the left side also.
• In this the enlarged goiter has gone in the chest in the anterior mediastinum.
Fig. 43: Collapse right lower lobe
Fig. 44: Collapse right lower lobe

CHEST 39
RIGHT LOWER LOBE COLLAPSE

1. Shadow in right lower zone with blunting of right costophrenic angle.
2. Pulled down oblique fissure on right side.
3. Shift of cardiac shadow to right side.
Fig. 45: Mass in right hilum (cancer)
Fig. 46: Mass in apical segment of right lower lobe

CHEST 41
CANCER IN RIGHT LOWER LOBE

In PA view there is a shadow in right hilum. In lateral view it is seen in the apical
segment or superior segment of right lower lobe.
Fig. 47: Cancer left lung
Fig. 48: Tumor left lower lobe with erosion of rib

CHEST 43
CANCER IN LEFT LUNG

1. In PA view there is a shadow in left mid zone.
2. In lateral view this shadow is seen located anteriorly in left upper lobe.
3. Destruction of the rib is seen.
Fig. 49: Cancer in left lung
Fig. 50: Cancer in left lower lobe
Fig. 51: Left side four rib thoracoplasty done four tubercular
cavity with massive hemoptysis
CHEST 45
CARCINOMA IN LEFT LOWER LOBE

1. Lobulated shadow in left hilum.
2. In lateral view, it is present in the apical segment of left lower lobe.
3. Lower lobe apical segment lesion can be confused with mass in upper lobe.
TUBERCULAR CAVITY LEFT UPPER LOBE OF LUNG WITH UPPER 4 RIBS

THORACOPLASTY ON LEFT SIDE
1. Cavity in the left upper lobe of lung.
2. Missing upper 4 ribs on left side.
3. Shift of mediastinum to left side.
Fig. 52: Cavity in Rt lower lobe of lung. Lung abscess
Fig. 53: Cyst in right lower lobe of lung

CHEST 47
CAVITY IN RIGHT LOWER LOBE OF LUNG

1. There is a shadow with air fluid level in right lower zone with surrounding
pneumonitis “lung abscess”.
2. Blunting of right castophrenic angle is seen.
CYST IN RIGHT LOWER ZONE OF LUNG

1. A rounded shadow is present in right lower zone with obliteration of right
costophrenic angle. It has a smooth density.
2. It is an infected lung cyst
Fig. 54: Cyst in left lower lobe of lung
Fig. 55: Calcified pericardium in constrictive pericarditis

CHEST 49
CYST IN LEFT LUNG

There is a large cyst in left lung. It has air fluid level showing that this cyst is communicating
with the bronchus.
CALCIFIED PERICARDIUM
On lateral view of chest you can see dense calcification on the anterior and basal
pericardium. This usually happens in constrictive pericarditis due to tuberculosis.
Fig. 56: Wagner’s granulomatosis
Fig. 57: Aortic arch aneurysm

CHEST 51
MULTIPLE ROUND SHADOWS IN BOTH LUNG FIELDS

• These could be secondaries metastasis in both lung fields.
• In some patients with anemia and epistasis such shadows can be seen in patients
with Wagner s granulomatosis.
• In Wagner granulomatosis cases PR3 and ANCA is positive.
SHADOW IN LEFT UPPER ZONE

There is a rounded globular shadow in left upper zone with collection in left pleural
cavity. Patient was in shock. It was a leaking aneurysm of the aorta (arch of aorta).
Fig. 58: Pericardial effusions
Fig. 59: Anterior mediastinal mass

CHEST 53
PERICARDIAL EFFUSION
• The cardiac shadow is enlarged on PA view.
• CT ratio is increased. Ultrasound showed collection of fluid in the pericardial cavity.
• Echocardiography confirmed presence of fluid in pericardial cavity.
ANTERIOR MEDIASTINAL MASS

• There is a mass in the anterior mediastinum on both sides.
• This is due to presence of nodes in the anterior mediastinum due to testicular tumor.
Fig. 60: Retrocardiac triangular shadow of hiatus hernia (paraesophageal)
Fig. 61: Barium meal showing hiatus hernia with volvulus

CHEST 55
RETROCARDIAC SHADOW WITH AIR FLUID LEVEL

This shadow is typical of hiatus hernia. When hiatus hernia is present and it is
incarcerated, one gets this shadow in retrocardiac region along with air fluid level.
Abdomen
Fig. 1: Dilated small bowel loops along with Fig. 2: Multiple fluid levels
fluid levels
Fig. 3: Distended small bowel loops Fig. 4: Dilated small bowel loops
ABDOMEN 59
Fig. 5: Dilated small bowel loops
Whenever a patient comes with acute abdomen, always take two views of plain X-ray
abdomen one in sitting position and other in lying down position to see for any gas
filled loops and air fluid levels.
SMALL BOWEL OBSTRUCTION

• Dilated loops are mostly central and numerous.
• Measure less than 5 cm in diameter.
• Have a small radius of curvature.
• Contain valvulae convitentes which pass right across the bowel lumen, are thin and
are close together.
• Fluid levels are seen in erect film, if more than 3-5 fluid levels are seen, it is suggestive
of small bowel obstruction.
Fig. 6: Dilated large gut loops
Fig. 7: Dilated large gut loops

ABDOMEN 61
LARGE BOWEL OBSTRUCTION

• Large bowel loops are peripheral.
• Loops have wide radius of curvature.
• Are greater than 5 cm in diameter.
• Contain Haustrations which are thick and widely separated.
Fig. 8: Caecal volvulus
Fig. 9: Large gut distended Fig. 10: Large gut volvulus

(sigmoid volvulus)
ABDOMEN 63
CAECAL VOLVULUS
• Massively dilated caecum in the central abdomen.
• Contains thick haustral markings.
SIGMOID VOLVULUS
• Grossly dilated Sigmoid colon arising from Pelvis.
• Lack of Haustral marking.
• Outer and inner walls of dilated loops converge in pelvis.
Fig. 11: Appendicolith

ABDOMEN 65
APPENDICOLITH
• Radio opaque shadow lying over right ileum bone.
• Shadow usually is outside the line of ureter.
• In acute appendicits there is localized ileus in the region of right iliac fossa.
Fig. 12: Free gas under diaphragm

ABDOMEN 67
PERFORATION OF GUT
• Presence of free gas under the diaphragm on one of both sides.
• At times this may be confused with colon lying between liver and diaphragm but
presence of haustral markings will make it clear that this is not free gas but colon
inter posed between diaphragm and liver.
• Free gas is usually seen under both domes of diaphragm.
Fig. 13: Carcinoma of ascending colon (see arrow)
Fig. 14: Cancer caecum (see arrow)

ABDOMEN 69
CARCINOMA OF COLON
• Seen on Barium enema as filling defect in colon. Always look for a second growth in
rest of the colon.
• See for rolled elevated margins “Apple Core” appearance.
CAECAL CARCINOMA
• Seen as irregular filling defect on the medial wall of the caecum.
• Contraction of distal part of caecum is seen due to compression and inversion by
tumor.
Fig. 15: Diverticulosis colon
Fig. 16: Roundworm in small gut Fig. 17: Roundworm in small gut
ABDOMEN 71
COLONIC DIVERTICULOSIS
• Multiple diverticuli are seen arising for descending and sigmoid colon.
• At times one of the diverticulum ruptures and forms a diverticular abscess.
WORM INFESTATION
• Roundworms are seen as filing defect in the loops of the small bowel.
• Barium is seen in the digestive tract of the worm in one film.
Fig. 18: Ulcerative colitis, barium ulcers in descending colon

ABDOMEN 73
ULCERATIVE COLITIS
• Single contrast barium enema shows multiple ulcerations and double contrast shows
irregular mucosal outline due to ulcerations.
• Subsequently, one gets rigid pipe like colon in a late case of ulcerative colitis.
Fig. 19: Growth in sigmoid colon with faecal impacting proximally
Fig. 20: Enteroclysis Fig. 21: Enteroclysis

ABDOMEN 75
FILLING DEFECTS IN COLON

• Filling defects in the sigmoid colon with ill-defined edges.
• Proximal to it there are multiple smooth filling defects surrounded by barium due to
lumps of feces.
• A good bowel preparation is very important before doing barium enema.
ENTEROCLYSIS (SMALL BOWEL ENEMA)

• This procedure distends the small bowel and gives excellent mucosal details.
• The disadvantage is that it requires intubation with a nasoduodenal tube, which is
passed to the duodenojejunal flexure.
• Barium is injected through the tube followed by water or methyl cellulose to propel
the barium through the small bowel.
Fig. 22: Enteroliths
Fig. 23: Enteroliths

ABDOMEN 77
ENTEROLITHS
• Calcified shadows seen in the lumen of the gut.
• These change their position when the position of the patient is changed as these are
lying in the lumen of the gut.
• Usually found in blind loops of the intestine which has strictures on both ends of the
blind loop.
Fig. 24: Liver abscess
Fig. 25: Liver abscess

ABDOMEN 79
LIVER ABSCESS
• C T scan showing single large homogeneous space occupying lesion into left lobe of
liver.
• On superolateral surface close to the upper surface of the liver it is threatening to
rupture.
Fig. 26: Splenic infarcts
Fig. 27: Splenic infarcts

ABDOMEN 81
SPLENIC INFARCTS
• CT scan showing enlarged spleen with hypodense shadows scattered allover.
• These are multiple splenic infarcts.
Fig. 28: Shadow in right lower quadrant
Fig. 29: CT scan showing the cystic lesion on skin

ABDOMEN 83
DENSE SHADOW IN THE X- RAY LOWER QUADRANT OF ABDOMEN

• A Radio opaque shadow is seen in right lower quadrant, close to L 4 and L5 vertebral
bodies.
• Shadow can be confused with stone in ureter but it is not longitudinally placed in
line of the ureter.
• Too big to be an appendicolith.
• On C T scan in the next film one can see it as a sebaceous cyst from the skin on the
posterior part of the body which can give dense shadow at times due to thick
sebaceous material present in it, white arrow shows it.
Fig. 30: Cancer caecum and ascending colon
Fig. 31: Linitis plastica Fig. 32: Linitis plastica

ABDOMEN 85
CANCER CAECUM AND ASCENDING COLON

• Irregular filling defect in caecum and ascending colon is seen.
LINITIS PLASTICA
• Small contracted stomach.
• Stomach does not expand even with introduction of gas and barium.
• It happens either due to primary cancer of stomach or involvement of stomach with
any other abdominal malignancy or ovarian carcinoma etc.
Fig. 33: Cancer stomach
Fig. 34: Growth in stomach

ABDOMEN 87
CANCER STOMACH
• Irregular filling defect in the wall of the stomach.
Fig. 35: Pseudopancreatic cyst

ABDOMEN 89
PSEUDOPANCREATIC CYST
• Pseudocyst in the body of the pancreas.
• Homogeneous density.
• Well defined wall of the cyst is seen.
• Cyst is compressing the stomach anteriorly.
Fig. 38: Diverticulae in descending and sigmoid colon

ABDOMEN 91
DIVERTICULAR DISEASE OF COLON

• Numerous diverticuli are seen arising from the sigmoid and the descending colon.
Fig. 39: Crohn’s disease stricture of gut
Fig. 40: Crohn’s disease

ABDOMEN 93
Fig. 41: Crohn’s disease stricture (white arrow) cobblestone (black arrow)
CROHN’S DISEASE
• Deep ulcerations of the bowel wall.
• Sparing of rectum.
• Involvement of the distal ileum.
• Skip lesions with intervening normal bowel.
• Shaggy outline of the bowel wall due to mucosal ulcerations.
• Loss of normal haustra.
• Narrowing of the gut.
• Cobblestone appearance due to island of mucosa between two large bridging ulcers.
• Shaggy outline of the affected bowel wall due to ulceration.
Fig. 42: Duodenal diverticulum
Fig. 43: Duodenal diverticulum from second part of duodenum

ABDOMEN 95
DUODENAL DIVERTICULUM
• Barium meal showing presence of barium in stomach and duodenum.
• From the second part of duodenum, there is a sac-like diverticulum projecting out.
Fig. 44: Stomach volvulus
Fig. 45: Complete volvulus stomach

ABDOMEN 97
VOLVULUS OF STOMACH
• There is complete volvulus of stomach.
• The gastroesophageal and pyloroduodenal junctions are lying at the same position
due to volvulus.
Fig. 46: Annular pancreas
Fig. 47: Tricho bezoar

ABDOMEN 99
ANNULAR PANCREAS
• Barium swallow, lateral view showing opacification of stomach and proximal
duodenum and barium is going distal to it slowly. But in the mid second part of
duodenum, there is no opacification.
• This is due to presence of annular pancreas compressing the duodenum.
TRICHO BEZOAR
• Seen as a filling defect in the Pylorus.
• A ball of hairs in the stomach seen usually in mentally retarded people who swallow
their hairs.
Fig. 48: Pyloric stenosis
Fig. 49: Pyloric stenosis

ABDOMEN 101
PYLORIC STENOSIS
• Gross dilatation of the stomach with narrowing in the pyloric region.
Fig. 50: Splenoporto-

venogram

venogram

venogram
ABDOMEN 103
SPLENOPORTOVENOGRAM
• Shows injection of dye in the spleen. From there it fills the splenic vein. Portal vein
and communicating channels are seen upto lower end of the esophagus and fundus
of the stomach due to varices.
Fig. 53: Tablets in stomach
Fig. 54: Calcified nodes abdomen

ABDOMEN 105
FOREIGN BODY IN STOMACH

• Plain Skiagram of abdomen showing gas in stomach and multiple round tablets in
stomach.
• These are undissolved tablets lying in stomach. There are herbal tablets containing
some heavy metal in them.
CALCIFIED LYMPH NODES IN ABDOMEN

• Nodes is pelvis and all along the inferior vena cava in the abdomen and these are
calcified.
• These are calcified abdominal nodes.
Fig. 55: Roundworm in small gut
Fig. 56: Roundworm in small gut

ABDOMEN 107
ROUNDWORM IN THE INTESTINE

Barium meal showing the presence of tubular filling defects in the lumen of the small
intestine. in one of them there is barium meal in the gut of the roundworm.
Fig. 57: Massive pneumoperitoneum
Fig. 58: Calcified aorta

ABDOMEN 109
MASSIVE PNEUMOPERITONEUM
• Due to rupture of colon, there is massive collection of the air in the peritoneal
cavity, pushing the liver and spleen medially.
CALCIFICATION OF ABDOMINAL AORTA

• In lateral view one can see longitudinal calcification anterior to the vertebral bodies.
Fig. 59: Leiomyoma stomach
Fig. 60: Eventration of left diaphragm

ABDOMEN 111
LEIOMYOMA STOMACH
• Large filling defect in the lumen of the stomach attached to the greater curvature.
• There is some barium in the filling defect. This is typical of leiomyoma.
EVENTRATION
• Left dome of diaphragm is elevated in the PA view with segmental atelectasis of left
lower lobe of lung.
• Lateral view of chest shows elevated left dome of diaphragm.
Fig. 61: Sponge left in the abdomen
Fig. 62: Cancer rectum

ABDOMEN 113
FOREIGN BODY SPONGE IN ABDOMEN

• X-ray abdomen showing an ill-defined shadow in left upper quadrant of abdomen
with air bubbles entrapped in it. This shows the presence of a left over foreign body
(Abdominal Sponge) in the abdomen.
• Presence of air bubbles in a foreign body are typical of a retained sponge.
CANCER RECTUM
• On Barium Enema, there is a filling defect in rectum with irregular margins with
proximal colonic dilatation.
Fig. 63: Napkin ring deformity in cancer ascending colon
Fig. 64: Calcification of pancreas

ABDOMEN 115
CANCER COLON
• Irregularity of ascending colon upto hepatic flexure with napkin ring deformity.
CALCIFIED PANCREAS
• On C T scan one can see pancreas lying behind the stomach and in pancreas, there
is scattered calcification all over the gland.
• It is commonly seen in chronic pancreatitis.
Fig. 65: Appendicular abscess pushing loop of ileum medially
Fig. 66: Paraesophageal hernia

ABDOMEN 117
APPENDICULAR ABSCESS
• On Barium examination, one can see that large appendicular mass has pushed the
gut medially.
• On ultrasound examination the mass had fluid.
• This was an appendicular abscess which had pushed the gut medially.
PARAESOPHAGEAL HERNIA
• On barium meal, one can see a portion of stomach which has moved in the chest
and is lying adjacent to the esophagus.
• This is paraesophageal hernia.
Fig. 67: Sliding hiatus hernia

ABDOMEN 119
SLIDING HIATUS HERNIA

• One can see that a portion of stomach has been pulled in the chest. It has slided in
the long axis of esophagus.
• There is also an ulcer present on the lesser curvature of the stomach just after the
junction of the intrathoracic and intra-abdominal portions of the stomach.
Fig. 69: Loupe in uterus
Fig. 70: Duodenal atresia Fig. 71: Barium meal in duodenal atresia
ABDOMEN 121
FOREIGN BODY IN PELVIS

• A coiled spring like foreign body is lying in the pelvis inside the uterus. It is a loupe
lying in its normal position in the uterus.
• It is a commonly used female contraceptive device.
DUODENAL ATRESIA
• Double bubble appearance in the upper abdomen due to duodenal atresia.
• This is further confirmed by barium meal of upper GIT.
Fig. 72: Foreign body tooth brush in stomach
Fig. 73: Tooth brush in stomach

ABDOMEN 123
Fig. 74: Safetypin in stomach
FOREIGN BODY IN STOMACH

• A longitudinal body is seen in the left upper quadrant of the abdomen.
• On closer examination it appears to be toothbrush which has been accidentally
swallowed by the patient.
• In another X-ray, one can see a safetypin lying in the stomach.
Fig. 75: Copper”T” lying free in peritoneal cavity
Fig. 76: Splenic abscess

ABDOMEN 125
FOREIGN BODY IN PERITONEAL CAVITY

• A foreign body is lying in the abdomen. It looks like a Copper T.
• History was given by the patient that she had a copper T inserted and now she
cannot feel the thread which she could feel before in the vagina.
• ‘Copper T has perforated the uterus and is lying free between the small bowel
loops.
• It was successfully removed by laparoscopy.
SPLENIC ABSCESS
• On CT scan in the spleen there is a large hypodense mass which has fluid values.
• This is large splenic abscess.
Genitourinary
Fig. 1: Stone lower end of right ureter
Fig. 2: Triple ureter right side

GENITOURINARY 129
LOWER URETERIC CALCULUS

1. Calculus in lower ureter.
2. Hydroureter and hydronephrosis
IPSILATERAL TRIPLE URETER

• IVP showing three ureters in the pelvis on right side. It is a rare entity.
Fig. 3: Bilateral gross reflux
Fig. 4: Right side gross ureteric

reflux
Fig. 5: Bilateral gross reflux and

hydroureters
GENITOURINARY 131
VESICOURETERIC REFLUX
1. This is a micturating cystourethrogram showing filling of both ureters due to vesico-
ureteric reflux.
Fig. 6: Ureterocele (right)
Fig. 7: Ureterocele (left)
Fig. 8: View of right

ureterocele
GENITOURINARY 133
URETEROCELE
• The lower end of ureter is dilated. It causes a smooth filling defect in the bladder
and is called a ureterocele. There is a clear halo around it.
Fig. 9: Thimble bladder
Fig. 10: Crossed renal ectopia

GENITOURINARY 135
THIMBLE BLADDER
• Very small contracted urinary bladder is seen in the pelvis. It is usually seen in
tubercular disease. The capacity of this bladder is much reduced.
CROSSED RENAL ECTOPIA

• Intravenous pyelography showing right kidney and ureter are in its normal position.
Left kidney is lying below the right kidney as it has crossed across the midline but the
left ureter cross the midline and opens on the left side in the urinary bladder.
Fig. 11: Retrocaval ureter Fig. 12: Retrocaval ureter
Fig. 13: Foreign body in bladder

GENITOURINARY 137
RETROCAVAL URETER
• Intravenous pyelogram showing indentation in the upper ureter on right side close
to the renal pelvis, showing retrocaval position of the ureter.
FOREIGN BODY IN URINARY BLADDER

• There is a tubular structure lying in urinary bladder.
• It is a retained piece of a red rubber cather which got encrustated due to deposition
of salts and is seen as a Radio opaque foreign body in the urinary bladder.
Fig. 14: Stricture urethra
Fig. 15: Urethral diverticulum
Fig. 16: Urethral diverticulum

GENITOURINARY 139
STRICTURE URETHRA
• There is stricture of proximal urethra as seen in retrograde urethrogram.
DIVERTICULUM URETHRA
• Sac-like diverticulum is seen in the penile urethra.
Fig. 17: Double collecting system on left side
Fig. 18: Calcified vas deferens

GENITOURINARY 141
DOUBLE RENAL COLLECTING SYSTEM

• On left side, there are separate collecting system for upper calyx and other from
middle and lower calyx. These unite subsequently one from a single ureter on left
side.
CALCIFIED VAS DEFERENS

• Seen as obliquely placed tubular structures in the pelvis.
• Usually seen in elderly people with enlarged prostate.
Fig. 19: Calcified urinary bladder in schistosomiasis
Fig. 20: Calcified schistosomia in urinary bladder

GENITOURINARY 143
CALCIFIED URINARY BLADDER

• The wall of urinary bladder is calcified. This is usually seen in schistosomiasis.
CALCIFIED SCHISTOSOMIA
• In the bladder in the pelvis one can see horizontally lying tubular calcified structure
close to each other.
• These are schistosomia present in bladder.
Fig. 21: Double urinary

bladder
Fig. 22: Stone urinary

bladder
Fig. 23: Stone urinary

bladder
GENITOURINARY 145
DOUBLE URINARY BLADDER

• Cystogram showing two separate urinary bladders with two separate urethral
openings.
STONE IN URINARY BLADDER

• Radio opaque shadow in the pelvis in the region of urinary bladder.
Fig. 24: Bladder diverticuli due to posterior urethral valve
Fig. 25: Tuberculosis of kidney with stricture left ureter in upper third
GENITOURINARY 147
POSTERIOR URETHRAL VALVE

• There is a filling defect in posterior urethera. It is a valve like structure.
• Shows hypertrophy of bladder with multiple diverticulum one diverticulum is large.
TUBERCULOSIS OF KIDNEY WITH STRICTURE OF URETER IN UPPER 3rd

• Deformed pelvicalyceal system of left ureter—evidence of tubercular infection.
• Stricture in upper third of ureter due to tubercular infection.
• Distal ureter also has a beaded appearance due to infection.
Fig. 26: Bilateral PUJ block
Fig. 27: Diverticulum bladder with stricture urethra

GENITOURINARY 149
PELVI URETERIC JUNCTION BLOCK

• IVP showing hydrocalycosis and hydronephorsis on both sides with sudden block at
PUJ showing bilateral PUJ Block.
STRICTURE URETHRA WITH DIVERTICULA OF BLADDER

• Urinary bladder shows a diverticula with stricture in urethra.
Fig. 28: Foreign body in urinary bladder (clip of pen)
Fig. 29: Mass lower pole of right kidney

compressing calyces
GENITOURINARY 151
FOREIGN BODY IN BLADDER

• There is a foreign body in urinary bladder with deposition of calcium salts on it. It is
a pen cover with a clip-plastic and metal portion covered with salts.
MASS LOWER POLE OF RIGHT KIDNEY

• The upper lobe and middle calyces are compressed on right side and pushed up.
• Lower lobe is enlarged due to a mass in the lower lobe. It was a renal cell carcinoma.
Fig. 30: Tuberculosis of right ureter with thimble bladder
Fig. 31: Malrotated right kidney pelvis is directed anteriorly

GENITOURINARY 153
TUBERCULOSIS OF GENITOURINARY TRACT

• Right side calyces are spastic and dilated.
• Hydroureter on the right side.
• Narrowing of the ureter at the lower end.
• Contracted small urinary bladder is thimble bladder. These are all features of renal
tuberculosis.
MALROTATED RIGHT KIDNEY

• The right ureter is starting from the anterior surface of pelvis and not from medial
surface. This is due to malrotation of right kidney. It is usually seen in horseshoe
kidney.
Fig. 32: Osteosclerotic secondaries from cancer prostate
Fig. 33: Carbuncle right kidney

GENITOURINARY 155
PROSTATE SECONDARIES
Osteosclerotic secondaries are seen in the pelvis and lumbosacral vertebrae. These are
typical of prostate secondaries.
EMPHYSEMATOUS PYELONEPHRITIS
One can see presence of air in the region of the kidney and it is extending upwards. It
is surrounding the whole of right kidney.
This is due to infection with gas forming organisms, and that is commonly seen in
cases of diabetes with renal infection.
Hepatobiliary
Fig. 1: Oral cholecystogram Fig. 2: Oral cholecystogram

(Radiopaque dye)
Fig. 3: Oral cholecystogram Fig. 4: Oral cholecystogram (dye in gut)

HEPATOBILIARY 159
For hepatobiliary disorders radiological investigations done are:

1. Ultrasound upper abdomen
2. Plain or contrast CT scan of upper abdomen
3. ERCP
4. MRCP
ORAL CHOLECYSTOGRAM
• Multiple filling defects within the contrast filled gallbladder.
• Radio opaque dye is seen in the gut.
Fig. 5: Intravenous cholangiogram
Fig. 6: Operative cholangiogram Fig. 7: Operative cholangiogram

HEPATOBILIARY 161
CHOLANGIOGRAM (IVC) INTRAVENOUS CHOLANGIOGRAPHY

CBD filled with contrast is seen and no Radio opaque dye is seen in the gut.
This test is not done nowadays due to the risk of reaction to the contrast.
OPERATIVE CHOLANGIOGRAM
See Presence of Towel clips or artery forceps in the field of the picture. Bile duct is
outlined. The concentration of the dye is more than seen in I.V. Cholangiogram See for
any filling defect in the bile duct and for flow of dye in the duodenum.
Fig. 10: Operative cholangiogram

Fig. 13: ERCP showing pancreatic duct. Normal ERCP showing bile duct
HEPATOBILIARY 163
OPERATIVE CHOLANGIOGRAM WITH STONE IN CBD

• Shows filling of CBD and blocked lower end of CBD.
• No dye is going in the duodenum.
ERCP
• Shows filling of CBD and pancreatic duct. You can see the scope in the duodenum.
Fig. 14: T-tube cholangiogram showing

residual stone in CBD
Fig. 17: T-tube cholangiogram
Fig. 15: T-tube cholangiogram
Fig. 18: T-tube cholangiogram with filling

Fig. 16: T-tube cholangiogram defects in CBD
HEPATOBILIARY 165
T-TUBE CHOLANGIOGRAM
• Long T-tube seen with dye in it.
• Dye going in CBD with filling defect in CBD.
• Dye is not passing in the duodenum
• In one of the cholangiogram, dye is passing into duodenum and there are no filling
defects in CBD.
Fig. 19: ERCP showing bile duct and post lap Fig. 20: ERCP showing stent in CBD
cholecystectomy clips
Fig. 21: MRCP showing stones in gallbladder Fig. 22: MRCP showing stones in gallbladder
and CBD and one stone in CBD is only partially blocked
as dye is going in the duodenum
HEPATOBILIARY 167
ERCP SHOWING BLOCKAGE IN THE CBD

• Stent has been put in for relieving obstruction in CBD.
MRCP
• MRCP images of biliary tree showing filled GB and bile duct without any obstruction
as the dye is seen in the duodenum.
Fig. 23: ERCP showing block at lower end of CBD due to stricture
Fig. 24: ERCP showing roundworm in CBD Fig. 25: IVC showing roundworm in
CBD
HEPATOBILIARY 169
ERCP SHOWING FILLING OF CBD

• ERCP showing filling of CBD with dye and with blockage at it lower end.
ROUNDWORM IN A DILATED CBD

• On ultrasound one may see roundworm as a moving worm in CBD.
• On ERCP one can see a linear on curled up filling defect in the dilated CBD.
Fig. 26: Oral cholecystogram showing a choledochal cyst
Fig. 27: CT scan showing right lobe abscess
Fig. 28: CT scan showing multiple liver abscess

HEPATOBILIARY 171
CHOLEDOCHAL CYST
• Oral cholecystogram showing gallbladder and common bile duct and an outpouching
of CBD as a cystic structure—Choledochal cyst.
AMOEBIC LIVER ABSCESS

• On ultrasound it is seen as a hypoechoic lesion in liver.
• C T scan confirms presence of abscess and it also shows whether it has leaked or not.
Fig. 29: Right lobe liver abscess

Fig. 30: Intrahepatic dilatation of biliary tree due to obstruction at portahepatis
Fig. 31: Intrahepatic biliary dilatation

HEPATOBILIARY 173
MASS OF NODES AT PORTAHEPATIS BLOCKING COMMON HEPATIC DUCT

Enlarged nodes in cancer of gallbladder seen as a mass of nodes in Portahepatis blocking
the common hepatic duct and dilation of intrahepatic biliary radicals.
Fig. 32: Calcified hydatid cyst liver Fig. 33: Calcified hydatid cyst of liver
Fig. 34: Gas in biliary tree

HEPATOBILIARY 175
CALCIFIED HYDATID LIVER

Calcified rounded density in the region of right lobe of liver. It is calcified hydatid cyst
of liver seen in PA and lateral views.
GAS IN BILIARY TREE

On a plain X-ray in lying down position, one can see free gas in the liver region. This is
due to an anastomosis between CBD and gastrointestinal tract, e.g. choledocleo
duodenostomy or choledochojejunostomy.
Fig. 35: Large hydatid cyst in right lobe of liver
Fig. 36: Two hydatid cysts in liver

HEPATOBILIARY 177
HYDATID CYST OF LIVER

• CT scan of a 25-year-old lady in coronal section shows two large hydatid cysts in
liver.
• This can be seen clearly on the sagittal view of CT scan also.
BARIUM IN CBD
On barium swallow and meal, the barium gas from duodenum in the biliary tree showing
a patient choledochoduodenostomy anastomosis.
Fig. 37: Barium in CBD

Important X-rays of
Head and Neck
Fig. 1: Cervical ribs
Fig. 2: Fracture ribs
Fig. 3: Skull without sutures

IMPORTANT X-RAYS OF HEAD AND NECK 181
CERVICAL RIB
• Rib arising for C 7 vertebra. It may be complete or partial
• May be unilateral or bilateral
• C T scan reconstruction can make it very clear whether cervical rib is present or not.
• Proper AP view of neck should be taken to identify the cervical Rib. In chest X-ray at
times, the cervical ribs may not be clearly visible if lower neck portion has not been
properly included in it.
• In one of the X-ray cervical rib is seen on the left side.
On the left side there is an extra rib in the neck, which is a cervical rib.
One has to look for this carefully or else it can be wrongly + passed as normal.
FRACTURE RIBS
Most of the times PA view of chest shows fracture of ribs clearly but at times if it is not
seen and if there are clinical signs of fracture ribs locally, then oblique view of the chest
has to be taken to see for the fracture.
CRANIOSYNOSTOSIS
No sutures are seen in the skull. All sutures are fused together as seen in both the views.
Fig. 4: Calcified thyroid nodule
Fig. 5: Thyroglossal fistula and tract upto base of tongue

CALCIFIED THYROID NODULE

1. Calcification is seen in the right lobe of thyroid gland.
THYROGLOSSAL FISTULA
1. Dye has been injected in the fistula and whole fistula tract has been outlined upto
base of tongue in the mouth.
Fig. 6: Large right submandibular duct stone

CALCULUS IN SUBMANDIBULAR DUCT

1. It is an intraoral view of floor of mouth.
2. On right side one can see a large stone in right submandibular duct in floor of the
mouth.
Breast
Fig. 1: Popcorn calcification in benign

lesion of breast
A B
Figs 2A and B: Calcification in benign lesion of breast
Fig. 3: Calcification in breast (benign)

BREAST 189
BENIGN LESION IN BREAST

Coarse calcification like popcorn type calcification seen in mass lesion in breast and is
indicative of benign lesion in breast.
As opposed to this in malignant lesion in breast, one sees a micro-calcification on
Mammography (see Fig. 5).
Fig. 4: Ductogram showing duct ectasia
Fig. 5: Micro-calcification in malignant lesion of breast

BREAST 191
DUCTOGRAM
Dye has been injected into one of the ducts of mammary gland showing dilatation of
duct (Duct ectasia).
MALIGNANT CALCIFICATION BREAST

Typical clusters of branching ductal or casting type calcification.
Calcification is irregular in outline and is of variable shape and density and is micro-
calcification.
Fig. 6: Micro-calcification in malignant lesion

BREAST 193
MAMMOGRAM—FINE CALCIFICATION
Fine calcification or micro-calcification seen in mammogram is suspicious of a malignant
lesion in that area of breast.
This is in contrast of a Popcorn Calcification in a benign fibroadenoma.
Fig. 7: Fibroadenoma Fig. 10: Fibroadenoma
Fig. 8: Fibroadenoma
Fig. 11: Fibroadenoma breast
Fig. 9: Giant fibroadenoma

BREAST 195
SOLID LESION IN BREAST

One can see a well rounded shadow in the breast mammogram. It is a fibroadenoma.
Fig. 12: Cancer breast irregular margins Fig. 13: Cancer breast irregular
margins
Fig. 14: Malignant growth breast

BREAST 197
MALIGNANT LESION IN BREAST

Irregular shaped lesion is seen in breast with varying areas of different density.
It is shadow of cancer breast.
Fig. 15: Fibroadenosis

BREAST 199
FIBROADENOSIS
Varying areas of solid and cystic density are seen scattered over the breast tissue. This is
fibroadenosis.
Bones
Fig. 1: Bone metastasis with fracture Fig. 2: Secondary deposit in bone

humerus
BONES 203
BONE METASTASES WITH PATHOLOGICAL FRACTURE

• Irregularity of upper end of humerus with destruction of bone and a pathological
fracture due to secondaries from carcinoma of thyroid.
Fig. 3: Giant cell tumor of bone Fig. 4: Giant cell tumor of bone
Fig. 5: Giant cell tumor of bone

BONES 205
GIANT CELL TUMOR OF BONE

• Soap bubble appearance of the distal end of major bones with expansion of bone.
Fig. 6: Fibrous dysplasia of ribs on left side
Fig. 7: Fibrous dysplasia

BONES 207
FIBROUS DYSPLASIA
• Affects one or several bones. It occurs most commonly in the long bones and ribs as
a lucent area with a well defined edge and may expand the bone.
• There may be sclerotic rim around the lesion.
Fig. 8: Enchondroma
Fig. 9: Fracture coccyx with posterior displacement

BONES 209
ENCHONDROMA
• Enchondroma are seen as expanding lesions most commonly in the bones of the
hand. These often contain a few flecks of calcium.
FRACTURE COCCYX WITH POSTERIOR DISPLACEMENT

• X-ray shows fracture of terminal end of coccyx and the distal fragment is displaced
posteriorly.
Esophagus
Fig. 1: Achalasia cardia Fig. 2: Achalasia cardia
Fig. 3: Achalasia cardia

ESOPHAGUS 213
Fig. 5: Achalasia cardia with dilated esopha-

gus in Rt. paracardiac region

ESOPHAGUS 215
ACHALASIA CARDIA
• Barium swallow shows a moderately dilated esophagus with tapering at the lower
end “rat tail appearance”.
• If dilated tortuous esophagus is present, it is seen as sigmoid esophagus with
prominence of the esophagus on the right side of mediastinum. It is filled with gas
and food. It may have a fluid level.
Fig. 7: Cancer esophagus Fig. 8: Cancer esophagus
Fig. 9: Cancer esophagus

ESOPHAGUS 217
CANCER ESOPHAGUS LOWER END

• Irregular filling defect in lower end of esophagus.
• Shouldering at the lower end of esophagus, showing the presence of a growth.
• In CT scan it may show involvement of the wall, surrounding structures and lymph
nodes.
Fig. 10: Stricture esophagus Fig. 11: Stricture esophagus
Fig. 12: Stricture esophagus

ESOPHAGUS 219
STRICTURE ESOPHAGUS
• Proximal dilation in upper esophagus.
• Long tight stricture in the distal end of esophagus.
Fig. 13: Esophageal diverticulum
Fig. 15: Pharyngeal diverticulum

ESOPHAGUS 221
ESOPHAGEAL DIVERTICULUM
• Can be seen as a pouch like structure from the esophagus. It starts anteriorly first and
then when enlarged, it shifts to left side.
• Diverticulum could be seen in mid or lower esophagus also.
ROLLING HIATUS HERNIA/PARA ESOPHAGAL

• Barium meal showing a pouch like projection of fundus adjacent to lower end of
esophagus in the chest and compressing it partially.
PHARYNGEAL POUCH OR ZENKER’S DIVERTICULUM

• Large pharyngeal pouch well outlined with barium.
Fig. 16: Achalasia with dilated torturus esopha- Fig. 17: Esophageal varices
gus with food material nil
Fig. 18: Esophageal varices Fig. 19: Esophageal varices

ESOPHAGUS 223
ESOPHAGEAL VARICES
• Barium swallow with multiple grape like filling defects along its lower end. This is
due to presence of esophageal varices due to portal hypertension.

ESOPHAGUS 225
HIATUS HERNIA (SLIDING)

• Barium meal showing projection of a portion of stomach in the mediastinum.
ESOPHAGEAL DIVERTICULUM
• There are sac like protrusions from the esophagus in upper and lower esophagus.
• These are of two types:
a. Pulsion diverticulum: due to high pressure in upper esophagus.
b. Traction diverticulum: when there are tubercular nodes in mediastinum which
when heal, pull out a wall of esophagus with it, as seen in or mid esophagus.
Fig. 23: Esophageal polyp
Fig. 24: Esophageal polyp

ESOPHAGUS 227
ESOPHAGEAL POLYP
• Filling defect seen in the lower end of esophagus, attached to one wall.
• In one of the views a pedicle is seen with the polyp.
Fig. 25: Cork screw esophagus

ESOPHAGUS 229
CORK SCREW ESOPHAGUS

• Tertiary contractions are seen in esophagus due to motility disorder of esophageal
lower end, giving rise to concertina effect seen as cork screw esophagus.
Miscellaneous
Fig. 1: Traumatic diaphragmatic hernia (Left)
Fig. 2: Arteriogram of leg

MISCELLANEOUS 233
RUPTURED DIAPHRAGM
• Stomach has entered in the left thoracic cavity and dilated.
• Collapse of base of left lung.
• Displacement of the heart to the opposite side.
LEG ARTERIOGRAM
• Showing irregular blocks in the popliteal artery with some collaterals.
Fig. 3: Skin wart on breast
Fig. 4: Skin wart on breast

MISCELLANEOUS 235
WART
• Skin lesions such as the wart may be mistaken for parenchymal lesion of the breasts;
so look carefully.
• Clinical examination will clear any doubt.
Fig. 5: Moth eaten appearance of skull
Fig. 6: Calcified hematoma (AP view)
Fig. 7: Calcified hematoma (Lateral view)

MISCELLANEOUS 237
MULTIPLE MYELOMA
Typical moth eaten appearance of the skull.
CALCIFIED SHADOW IN THIGH

• There is calcification on side of the femur bone but is not attached to it. It is a
calcified hematoma.
Fig. 8: Multiple neurofibromatosis
Fig. 9: Ribs in thalassemia major

MISCELLANEOUS 239
NEUROFIBROMATOSIS
• Multiple soft tisse shadows of different sizes are seen in the abdominal skiagram
right from periphery to central portion and its distribution is different to the distribution
of lymph nodes. Clinical correlation will prove these to be nodules in the
subcutaneous tissues of the abdomen.
THALASSEMIA
• Due to enlargement of marrow in the ribs, the ribs are enlarged. This happens in
thalassemia major and is very diagnostic of this condition.
Fig. 10: Accesory breast
Fig. 11: Aortogram showing blocked abdominal aorta

MISCELLANEOUS 241
ACCESSORY BREAST
• In the chest X-ray on the left side seen for a soft time lump in the left axilla.
• The location of this in axilla is typical of accessory breast tissue.
• The texture of this soft tissue lump is that of the breast on that side.
ABDOMINAL ARTERIOGRAM
• It is an arteriogram of the visceral vessels.
• All coeliac axis mesenteric and renal vessels are seen.
Fig. 12: Pellets in thigh Fig. 13: Metallic splinter in thigh
Fig. 14: Foreign body in esophagus

MISCELLANEOUS 243
FOREIGN BODY IN THIGH

• Multiple round foreign body are lying in thigh. These are pellets lying in the thigh.
FOREIGN BODY IN ESOPHAGUS

• You can see a round opaque foreign body in upper esophagus.
• It was a five rupee coin which was successfully removed by rigid esohpagoscope.
Fig. 15: Gas in wall of gallbladder
Fig. 16: Double uterus Fig. 17: Double uterus, each having separate tube
MISCELLANEOUS 245
CT SCAN SHOWING GAS IN THE WALL OF GALLBLADDER

This is a CT scan showing gas in the wall of the gallbladder. This is typical gas forming
organism infection in the gallbladder, i.e. emphysematous cholecystitis.
UTERUS DIDELPHUS
Hysterosalpingogram showing that there is common vagina and uterus has two cornua,
each having a separate fallopian tube.
Fig. 18: Calcified fibroids in uterus
Fig. 19: Dermoid cyst Fig. 20: Dermoid cyst with teeth
MISCELLANEOUS 247
CALCIFIED FIBROID UTERUS

Multiple calcified rounded shadows are seen in the pelvis. These are multiple fibroid
uterus which are calcified.
DERMOID CYST IN PELVIS

Presence of calcified structure in pelvis afacent to urinary bladder on CT scan.
On plain CT scan one can see calcification in pelvis on one or the other side,
depending where the dermoid is present.
This calcification may be in the form of teeth like structures at time.
Fig. 21: Cysticerci

MISCELLANEOUS 249
CYSTICERCI
In the X-ray, see for some calcified spots in the subcutaneous tissues. These are calcified
cysticerci.
Index
A Cavity in right lower lobe of lung Enteroclysis 75

47 Enteroliths 77
Abdomen 57 Cervical rib 181 ERCP 163
Abdominal arteriogram 241 Chest 1 Esophageal
Accessory breast 241 Cholangiogram 161 diverticula 225
Achalasia cardia 215 Choledochal cyst 171 diverticulum 221
Air fluid level 55 Coarctation of aorta 11 polyp 227
Amoebic liver abscess 171
Collapse left varices 223
Annular pancreas 99
left lung 9 Esophagus 211
Anterior mediastinal mass 53
lower lobe 27 Eventration 111
Aortic knuckle 35
Colonic diverticulosis 71
Appendicolith 65 F
Congenital
Appendicular abscess 117
diaphragmatic hernia 5
Aspergilloma 27 Fibroadenosis 199
emphysema of lung 23
Cork screw esophagus 229 Fibroid uterus 247
B Fibrous dysplasia 207
Craniosynostosis 181
Barium in CBD 177 Crohn s disease 93 Filling defects in colon 75
Benign lesion in breast 189 Crossed renal ectopia 135 Filling of CBD 169
Blockage in CBD 167 CT scan 245 Foreign body
Bone metastases with Cyst in bladder 151
pathological fracture 203 left lung 49 esophagus 243
Bones 201 right lower zone of lung 47 lung 15,17
Breast 187 Cysticerci 249 pelvis 121
Bronchiectasis 37 peritoneal cavity 125
D sponge in abdomen 113
C stomach 105,123
Dense shadow in X- ray lower
quadrant of abdomen 83 thigh 243
Caecal
Dermoid cyst in pelvis 247 urinary bladder 137
carcinoma 69
volvulus 63 Diverticula of bladder 149 Fracture
Calcification of abdominal Diverticular disease of colon 91 coccyx 209
aorta 109 Diverticulum urethra 139 cervical ribs 25
Calculus in submandibular Double renal collecting system ribs 7,15,181
duct 185 141
Cancer Double urinary bladder 145 G
caecum and ascending Ductogram 191
colon 85 Gas in biliary tree 175
Duodenal
colon 115 Giant cell tumor of bone 205
atresia 121
esophagus lower end 217 diverticulum 95
left lung 43 H
rectum 113 E Hiatus hernia 225
right lower lobe 41
Emphysematous Hydatid
stomach 87
bulla 13 cyst of liver 177
Carcinoma
colon 69 pyelonephritis 155 liver 175
left lower lobe 45 Enchondroma 209 Hydropneumothorax 33
I Pelvi ureteric junction block Stricture

149 esophagus 219
Intravenous cholangiography Perforation of gut 67 ureter in upper 3rd 147
161 Pericardial effusion 53 urethra 139,149
Ipsilateral triple ureter 129 Pericardium 49 Surgical emphysema 15
Pharyngeal pouch 221
L Pneumothorax 19 T
Posterior displacement 209
Large bowel obstruction 61 Thalassemia 239
Leg arteriogram 233 Posterior urethral valve 147
Prostate secondaries 155 Thimble bladder 135
Leiomyoma stomach 111 Thoracoplasty 25,45
Linitis plastica 85 Pseudopancreatic cyst 89
Pseudotumor 7,29 Thyroglossal fistula 183
Liver abscess 79 Thyroid nodule 183
Lower ureteric calculus 129 Pulmonary Koch s 35
Pulmonary tuberculosis 21 Traumatic left diaphragmatic
Lymph nodes in abdomen 105 hernia 33
Pyloric stenosis 101
Tricho bezoar 99
M T-tube cholangiogram 165
R Tubercular cavity
Malignant
Retrocardiac shadow 55 left upper lobe 45
calcification breast 191
Retrocaval ureter 137 with fungal ball 23
lesion in breast 197
Retrosternal goiter 37 Tuberculosis of
Malrotated right kidney 153
Right lower lobe collapse 39 genitourinary tract 153
Mammogram 193
Rolling hiatus hernia/para kidney 147
Mass lower pole of right kidney
151 esophagal 221
Massive pneumoperitoneum Roundworm in U
109 dilated CBD 169
Ulcerative colitis 73
Mediastinal structures 5 intestine 107 Ureterocele 133
Morgagni hernia 31 Ruptured diaphragm 233 Urinary bladder 143
MRCP 167 Uterus didelphus 245
Multiple S
myeloma 237
Schistosomia 143 V
round shadows in both lung
fields 51 Shadow in Vas deferens 141
left upper lobe 21 Vesicoureteric reflux 131
N left upper zone 51 Volvulus of stomach 97
thigh 237
Neurofibromatosis 239 Sigmoid volvulus 63 W
Node right axilla 9 Sliding 119,225
Small bowel Wall of gallbladder 245
O bowel obstruction 59 Wart 235
enema 75 Worm infestation 71
Operative cholangiogram
Solid lesion in breast 195
161,163
Splenic X
Oral cholecystogram 159
abscess 125
infarcts 81 X-ray chest 3
P Splenoportovenogram 103 X-rays of head and neck 179
Pancoast tumor 13 Stone in

CBD 163
Z
Pancreas 115
Paraesophageal hernia 117 urinary bladder 145 Zenker s diverticulum 221

X Rays

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Interesting X-rays

Thoracic, Cardiovascular and General Surgeon

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

Interesting X-rays in General Surgery

© 2010, Jaypee Brothers Medical Publishers (P) Ltd.

First Edition: 2010

Typeset at JPBMP typesetting unit

3. Genitourinary ............................................................................................ 127

4. Hepatobiliary ............................................................................................. 157

5. Important X-rays of Head and Neck ....................................................... 179

6. Breast ......................................................................................................... 187

7. Bones ......................................................................................................... 201

8. Esophagus ................................................................................................. 211

9. Miscellaneous ........................................................................................... 231

Index ............................................................................................................ 251

Fig. 1: PA view of chest X-ray, lateral view

Fig. 2: AP view of chest

Fig. 4: Congenital diaphragmatic hernia

CONGENITAL DIAPHRAGMATIC HERNIA

Fig. 5: Fracture ribs with hemothorax

Fig. 6: PA view of pseudotumor or encysted Fig. 7: Lateral view of chest showing

PSEUDOTUMOR IN THE CHEST

Fig. 8: Calcified mode in axilla on right side

CALCIFIED NODE RIGHT AXILLA

COLLAPSE LEFT LUNG

Fig. 10: Coarctation of aorta with rib notching

Fig. 11: Rib notching seen in coarctation

Fig. 12: Emphysematous bulla in right lung

Fig. 13: Pancoast tumor in right apex

Fig. 14: Fracture ribs

FRACTURE RIBS WITH SURGICAL EMPHYSEMA

FOREIGN BODY IN THE LUNG

Fig. 17: Nail in right bronchus PA view

Fig. 18: Lateral view showing nail in bronchus

FOREIGN BODY IN LUNG

Fig. 19: Small pneumothorax in right base

Fig. 20: Pneumothorax in right side

Fig. 21: Pneumothorax in right chest with

Fig. 22: Massive pneumothorax in right chest

Fig. 23: Neurogenic tumor in left apex

SHADOW LEFT UPPER LOBE

Fig. 26: Congenital emphysema of left lung

CONGENITAL EMPHYSEMA OF LUNG

TUBERCULAR CAVITY WITH A FUNGAL BALL

Fig. 28: Complete thoracoplasty left chest

Fig. 29: Cervical rib with fracture ribs

FRACTURE RIBS AND CERVICAL RIBS

Fig. 30: Collapsed left lower lobe with air bronchogram

Fig. 31: Bronchogram showing fungal ball in left apex

COLLAPSE LEFT LOWER LOBE

Fig. 32: Encysted effusion in fissure on right side

Fig. 33: Pockets of encysted effusions in Rh Baso + right parahilar regions

Fig. 34: Morgagni hernia

Fig. 35: Lateral view of anteriorly located Morgagni hernia

Fig. 36: Barium enemia showing presence of Morgagni hernia

Fig. 37: Congenital diaphragmatic hernia

Fig. 38: Left hydropneumothorax

TRAUMATIC LEFT DIAPHRAGMATIC HERNIA

Fig. 39: Pulmonary Koch

Fig. 40: Calcified aortic knuckle

CALCIFIED AORTIC KNUCKLE

Fig. 41: Cylindrical bronchiectasis right lower lobe

Fig. 42: Retrosternal goiter