2020 MIS II Revision Notes

Lecture --- Alternative & Addition View

1. Upper Extremities
Hand Norgaard’s projection (Ball catcher view)
Central ray • mid-way between the heads of the 5th metacarpals
• metacarpophalangeal joints
Demonstration
• interphalangeal joints
• rheumatoid arthritis
Pathology
• osteosclerosis (joint narrowing, increased density)
Remarks • Hand should be separated to avoid compression of soft tissue

Scaphoid PA with ulnar deviation Elongated PA with ulnar deviation

Central ray • scaphoid bone
• scaphoid is separated from • proximal part of scaphoid is not
Demonstration other carpal bone obscured
• radiocarpal joint can be shown
Pathology • fracture on scaphoid
Remarks • 10°/ 20°/ 30°

Scaphoid Anterior Oblique Posterior Oblique

Central ray • mid-way between radial and ulnar styloid process
• scaphoid in PA projection • scaphoid in lateral projection
Demonstration
• pisiform can be separated
Pathology • fracture on scaphoid

1. Proximal scaphoid fracture

2. Waist scaphoid fracture
3. Distal scaphoid fracture AO PO
Carpal Tunnel Supero-inferior Infero-superior
• vertical beam on mid-carpal • 25° – 30° cranial beam to mid-
Central ray
region carpal region
• arch of carpal bones: trapezium, scaphoid, capitate, hamate &
Demonstration
pisiform
Pathology • carpal tunnel syndrome (narrowing of carpal tunnel)
• Carpal tunnel:
1. carpal bones
Remarks
2. flexor retinaculum
3. median nerve & flexor tendon passing through the tunnel

Forearm PA Lateral
Central ray • mid-way between wrist & elbow joint
• proximal radius cross over • proximal radius & ulna are
proximal ulna obscured if elbow joint is
Demonstration
• Lateral elbow not extended
• Lateral wrist
Pathology • fracture
Remarks • Relationship between wrist and elbow is not changed

Elbow angle > 90° (# in proximal forearm) angle > 90° (# in distal humerus)
• 2.5 cm distal to mid-point • mid-way between two
Central ray
between two epicondyles epicondyles
• proximal radius & ulna is clearly • distal humerus is clearly shown
shown • elbow joint is partially obscured
Demonstration • elbow joint is partially obscured by proximal forearm
by distal humerus • proximal radius & ulna is
• distal humerus is distorted distorted
Pathology • fracture
 Elbow angle ≤ 90°
Central ray • mid-way between two epicondyles
• joint space is fairly seen
Demonstration
• distal humerus & proximal radius and ulna are distorted
Pathology • fracture

Elbow Supero-inferior Axial Infero-superior Axial

• 5 cm proximal to olecranon • 5 cm distal to olecranon
Central ray process (posterior aspect of process (posterior aspect of
upper arm) forearm)
Demonstration • distal humerus & proximal radius and ulna are superimposed
• dislocation
Pathology
• fracture fragment
Remarks • for patient with elbow fully flexed

Lateral elbow with medial rotated

Radial head &
Lateral elbow with pronated hand hand / lateral hand / lateral
neck
rotated hand
Central ray • lateral epicondyle of humerus
• radial tuberosity faces • radial tuberosity is obscured by
posteriorly radius
Demonstration
• radial head is partially obscured • radial head is partially obscured
by coronoid process by coronoid process

Proximal radioulnar joint AP

Central ray • 2.5 cm distal to mid-point between two epicondyles
• proximal radioulnar joint is clearly shown
Demonstration
• radial head & neck are projected clearly from the ulna
 Humerus Transthoracic Lateral
Central ray • centre ray passing through the neck of humerus
Demonstration • proximal humerus appears over the lung fields
• fracture
Pathology
• dislocation of fracture fragment

with arm with arm with arm

AP Shoulder with 25° caudad
supinated medially rotated laterally rotated
• vertical beam to humeral head • 25° caudally
Central ray to humeral
head
• tendon at the insertion of
supraspinatus teres minor subscapularis inferspinatus
and acromial
part of the
Demonstration superspinatus

Pathology • calcified tendon

AP Shoulder Lateral elbow & oblique elbow Stryker’s projection

• vertical beam to humeral head • 10° cranial beam to axilla
Central ray
(passing through humeral head)
• superior & inferior aspects of • anterior & posterior aspects of
Demonstration humeral heads humeral heads

Pathology • defect in humeral head

 Shoulder Supraspinatus Outlet view
Central ray • 15° caudal beam to 2.5 cm inferior to acromial end of clavicle
• scapula is seen in lateral position (Y-view)
• acromiohumeral space is appeared wider than lateral scapula position
Demonstration
• spurring of the lateral end of clavicle can be demonstrated
(osteoarthritis)
• osteoarthritis
Pathology
• osteophytes of acromion (removed by acromioplasty)

Acromioclavicular joint AP with weight bearing

• sternal notch (2 sides)
Central ray
• AC joint (1 side)
Demonstration • subluxation of the acromioclavicular joint (Pathology)
• 2 sides: compare the joint space on both sides
• exaggerating the effect of subluxation (especially for Type
I)

Remarks
2. Lower extremities
Foot Lateral with weight bearing
Central ray • bases of metatarsals
Demonstration • pes planus (loss of longitudinal plantar arch of foot)
• pes planus
Pathology • foreign body
• misalignment of the bone fragment (cross injury)
Remarks • stand up = weight bearing

Medial oblique 45° medial 45° lateral

Subtalar joint Lateral oblique
dorsiplantar oblique oblique
• vertical • 10° – 40° cranial • 15° cranial • 20° caudal
beam beam beam beam to
Central ray
• 2.5 cm anterior & 2.5 cm posterior to medial medial
malleolus malleolus

• anterior • posterior • posterior • middle &

articulation articulation of articulation posterior
of subtalar subtalar joint of subtalar articulation
joint viewed form joint of subtalar
anterior aspect viewed joint
• posterior ➔ form lateral • sinus tarsi
middle ➔ aspect
Demonstration
anterior part of
posterior
articulation
(10°➔20°➔40°)
 Calcaneus Lateral (single side) Lateral (double sides)
• 4 cm distal to medial malleolus • mid-way between medial
Central ray
malleolus
• whole calcaneus is demonstrated
Demonstration
• soft tissue of the heel should be seen
Pathology • calcaneal spurs / calcaneal fracture
• frog position
• foot should be separated to
Remark
avoid compression of soft
tissue

Calcaneus Supero-inferior Axial Infero-superior Axial

• 50° towards the toe to the • 40° cranially to the mid-line of
calcaneal tendon lateral malleolus
Central ray
• emerge at level of lateral
malleolus
Demonstration • calcaneal fracture (Pathology) (not for calcaneal spurs)
• wedge filter can be applied to compensate the difference of X-ray
Remarks
attenuation

Stress projection Stress projection

Ankle
(AP Forced inversion) (AP Forced eversion)
Central ray • mid-way between malleolus
Demonstration • widening of talo-fibular joint • widening of talo-tibial joint
• rupture or stretching of the • rupture or stretching of the
Pathology
calcaneo-fibular ligament medial (deltoid) ligament
• in means internally rotated • e means externally rotated
Remarks
• see the opposite side • see the opposite side
 Stress projection
Ankle
(Lateral)
Central ray • lateral malleolus
Demonstration • widening of talo-tibial joint
• rupture or stretching of the
Pathology anterior talo-fibular ligament
(subluxation)

AP oblique
Proximal tibiofibular joint Lateral oblique
(medial rotation)
• palpable head of fibula
Central ray

• proximal tibiofibular joint is clearly shown

• lateral femoral & tibial condyles
Demonstration
• medial aspect of patella
• head of fibula is separated from tibia
• subluxation
Pathology
• hair-line fracture in the head of fibula

Axial Patella
Laurin’s projection Hughston’s projection Merchant’s projection
(Skyline)
• cranial beam to • 45° cranial beam to • 60° caudal beam to
apex of patella a point just inferior a point just
to apex of patella proximal to the
superior pole of
Central ray
patella
Demonstration • patella-femoral interspace
• patella subluxation
Pathology
• longitudinal (直) fracture of patella

• subluxation can be • Alternative: patient

assessed without seated with same
stretching effect of angle between
quadriceps femur, lower leg &
centre ray
• Quantitative measurement of lateral patella-femoral angle for
Remarks
indirect evidence of patella subluxation

Normal Abnormal

Intercondylar fossa
Holmblad’s projection Camp-Coventry’s projection
(Tunnel View)
• popliteal region, emerge • 40° caudal beam to
from a point 1 cm inferior popliteal region, emerge
to the apex of patella from a point 1 cm inferior
Central ray
to the apex of patella

• middle & posterior part of • anterior & middle part of

intercondylar fossa intercondylar fossa
Demonstration • distorted
 • loose bodies in knee joint caused by osteochondritis
dissecans & chondrocalcinosis
• Avulsion fracture on intercondylar eminence due to
Pathology
strong stretching of cruciate ligament
• Avulsion fracture also happens in swing ankle
(ligament to base of the 5th metatarsal bone)
• Femur makes 20° to X-ray • Femur makes 50° to X-ray
beam beam

Remarks

Knee joint AP Erect AP Seated/Supine

Central ray • 1 cm inferior to apex of patella
• alignment of thigh and lower • widening of femoro-tibial joint
leg
• Varus (內翻) & Valgus (外
Demonstration
翻)

• Narrowing of joint space in

cases of arthritis Forced abduction Forced adduction

• osteoarthritis • subluxation of knee joint due to

Pathology rupture or stretching of
collateral ligament
• ab 走，ad 返

• see the opposite side

Remarks
 Pelvis Pelvis Inlet View Pelvis Outlet View
• 25° caudal beam to midline at • 40° cranial beam to midline at
Central ray level of ASIS level of inferior border of
symphysis pubis
• pelvic bone is symmetrical • pelvic bone is symmetrical
• contours of pelvic bone are well • contours of pelvic bone are well
Demonstration demonstrated demonstrated
• obstructor foramina
are symmetrical
• suspected pelvic or sacral fracture
Pathology
• sacroiliac or pubic bone misalignment
• 25° – 40° caudal beam • Male: 20° – 35° cranial beam
Remarks
• Female: 30° – 45° cranial beam

Hip joint Lateral (single hip) Lateral (both hip) (frog projection)
• mid-way between femoral • mid-line at level of femoral
Central ray pulse & palpable greater pulses (iliac crest 齊片頂 / ASIS
trochanter 落 8cm 入 4cm)

• distortion of femoral neck is • femoral head, femoral neck &

relatively less compared to acetabulum are well
Demonstration basic lateral position demonstrated

• Perthes disease (children)

Pathology • osteochondritis of the epiphysis
of femoral head
• rotate patient’s lower limbs
Remarks through 15° instead of 60° to
demonstrate femoral neck
Sacroiliac joint PA AP
• vertical / 25° – 30° caudal beam • vertical / 25° – 30° cranial beam
Central ray to midline at level of PSIS to midline at level between ASIS
& upper border of SP
• lumbosacral joint & sacroiliac joint can be demonstrated
Demonstration
• PA is better than AP
• ankylosing spondylitis (fusion of joint space)
Pathology
➔ bamboo spine (radiopaque)

Remarks

Sacroiliac joint Posterior Oblique

• vertical beam to 2.5 cm medial to the elevated ASIS (more common)
• 25 – 30° cranial beam to 2.5 cm medial & 2.5 cm inferior to the
elevated ASIS

Central ray

Pathology • ankylosing spondylitis (fusion of joint space)

• cranial beam: centre beam ⊥ long axis of joint
❖ elongated instead of foreshortened
• both sides should be taken for comparison
Remarks
3. Vertebral Column
Confused Words
• spondylitis (ankylosing spondylitis)
• spondylosis (cervical spondylosis)
• spondylolysis (pars interarticularis fracture)
• spondylolisthesis (pars interarticularis fracture + vertebral displacement)

Cervical spine Lateral (horizontal beam)

Patient • severe neck injury
Condition • lying spine
• patient’s shoulders need to be pulled by medical doctor wearing lead
Remarks apron
• better visualization of lower cervical vertebrae

C1-C2 AP
• mid-line at level of inferior border of upper incisors,
Central ray
passing through inferior edge of occiput
• fracture of odontoid process
Demonstration
• lower border of occiput & upper incisor are superimposed
• head lower down: upper incisor may superimpose the dens
• head raise up: occiput may superimpose the dens
• proper head tilting is required

Remarks
 Cervical Spine AO PO
• 15° caudal beam to midline at • 15° cranial beam to midline at
Central ray
level of 4th cervical vertebra level of 4th cervical vertebra
• intervertebral foramina
Demonstration
• both sides should be taken for comparison
Pathology • cervical spondylosis
• Neck collar
➢ do not remove & ask for help
• Turn head 45°
➢ avoid angle of mandible superimposing upper cervical
intervertebral foramina
• Tilt beam 15°
➢ vertebral foramina have 15° downwards
Remarks
• LAO → left • LPO → right
intervertebral foramina intervertebral foramina
• RAO → right RPO → left
intervertebral foramina intervertebral foramina

AO is preferred for cervical spine

AO PO
Patient’s • bucky is in front of the patients
stability ➢ patients can hold on
Radiation • patients are facing the image plate
If on strecher
Protection ➢ reduce thyroid / breast / lens dose
Image Quality • intervertebral foramina are closer to the film
➢ less magnification & geometric unsharpness
Cervical Spine Lateral with flexion Lateral with extension
Demonstration • subluxation of cervical spine for treatment process
• Whiplash injury
Pathology ➢ hyperextension/hyperflexion of the neck
➢ discontinuous anterior vertebral line
• crosswise • Lengthwise
Cassette
• 18×24 cm or 24×30 cm • 18×24 cm

Cervico- Localized view of C7-T1

thoracic (Swimmer’s position)
• 5 cm anterior to spinous process of the 7th vertebra
Central ray
• 5° – 10° caudal angulation if shoulder cannot be depressed
Demonstration • injury in C7-T11 for patient with thick shoulder (Pathology)
• weight bearing for one shoulder
humerus
Remarks
clavicle

Thoracic Spine PO
Central ray • mid-clavicular line of the raised side at T6 level
Demonstration • intervertebral articulation
Pathology • joint space narrowing by spinal disorder
• both sides (LPO & RPO) are taken for comparison

Remarks
 Lumbar Spine AO PO
• 2.5 – 5 cm lateral to mid-line on • along mid-clavicular line on
raised side at LCM level raised side at LCM level
Centre ray

Demonstration • pars interarticularis

• spondylolysis (fracture in pars interarticularis)
Pathology • spondylolisthesis (fracture in pars interarticularis
+ displacement of vertebra)
• LAO → right pars • LPO → left pars
interarticularis interarticularis
Remarks
• RAO → left pars • RPO → right pars
interarticularis interarticularis

Lumbar Spine Lateral with flexion Lateral with extension

• disc space narrowing
Demonstration
• instability of intervertebral joints
• bend by lumbar joint instead of hip joint
• can hold the patient’s pelvis
Remarks

Scoliosis
• Unnatural lateral curvature of vertebral column with rotation of vertebra
• Causes: idiopathic (commonest), neuropathic, osteopathic
• Cassette size: 30×90cm
• Patient erect: 1. curvature can be assessed under weight-bearing
2. supine positioning may underestimate curvature of the scoliotic spine
Radiation Protection
• Breast shield (not for rib cage assessed)
• Gonad shield
• Collimation should not be too tight to avoid second exposure
➢ If too tight, the spine may be cut off

Scoliotic Spine AP / PA AP / PA with lateral bending

Centre ray • mid-way between base of occiput & ASIS
• range of movement
➢ degree of correction of spine
Demonstration
can be obtained in planning
surgery
• need to perform both side
• pelvis should not be tilted
Remarks

Scoliotic Spine Lateral

Central ray • mid-axillary line at the level midway between EAM & ASIS
Demonstration • kyphoscoliosis (Pathology)
• curvature of the spine is convex to the film
(Two curvatures: take the larger angle one)

Remarks
 AP PA
• vertebral column is closer to film • breast dose 
➢ less magnification • thyroid dose 
Advantage ➢ less radiation doses to spinal • gonad dose 
cord & cerebrum
• easy to position
• breast dose  • vertebral column is far from
• thyroid dose  film
Disadvantage • gonad dose  ➢ more magnification
➢ more radiation doses to
spinal cord & cerebrum

Cobb angle
• two lines: upper endplate of the uppermost vertebra & lower endplate of the lowest
vertebra involved
• two curves: two Cobb angles
4. Skull
Occipital-mental View (OM View / Water’s view)
 occiput ➔ mental foramen of mandible
 radiographic baseline: orbitomeatal baseline (OML)
 demonstrate: 1. para-nasal sinuses (with mouth opening)
2. facial bones (with or without 30° caudal beam)
3. zygomatic arch (30° caudal beam)
4. orbits (radiographic baseline 35° with horizontal)
5. maxilla

Para-nasal
OM with open month
sinus
• fluid in sinuses
• mucosal thickening
Pathology
• suggestive sinusitis
• post-trauma fluid collection in sinus
• Tilting check: mid-sagittal plane // lateral border of image
• Rotation check: same distance between lateral border of skull &
lateral border of orbit
• Up & down check: petrous ridge is at the same level of the maxillary
antrum
➢ radiographic baseline 45° to beam
❖ Head lower down: petrous ridge is located higher than maxillary
Remarks
antrum & superimposed
➢ cannot tell fluid collection in maxillary sinus in case of sinusitis
• Open month: demonstrate sphenoid sinus
 Para-nasal
OF 15° Lateral
sinus
• fluid in sinuses
• mucosal thickening
Pathology
• suggestive sinusitis
• post-trauma fluid collection in sinus
• Horizontal beam: better
visualization of air-fluid level
Remarks

Facial bones OM OM with 30° caudal beam Lateral

Pathology • fracture
• zygomatic arch in profile

Remarks

Zygomatic Submental vertical FO with 30° caudal OM with 30° caudal

arch (SMV) beam beam
Pathology • fracture
• under-exposed for
the skull
Remarks
 Orbits OF with 25° caudal beam Modified OM
• fracture
Pathology
• foreign body
• frontal sinus can be well
demonstrated

Remarks
• differentiate the artifact of cassette & foreign body
➢ 2 OF 25° projections with different CR cassettes
➢ 2 OF 25° projections with different eye movements in DR cassette
❖ eye looks up + eye looks down (foreign body will move)

Maxilla OM
Pathology • fracture
Remarks • same as facial bones

Nasal bones Lateral Supero-inferior occlusal

Pathology • fracture & displacement of fracture fragment
• normally will not take this view

Remarks
 Mandible PA Lateral with oblique 30° beam
Pathology • fracture
• No AP due to the convexity of
mandible
• symphysis menti is
Remarks superimposed with the cervical
spine

Mandible AO Lateral
Pathology • fracture
• symphysis menti is separated • for gross injury
from cervical supine

Remarks

TM Joint Lateral with oblique 25° beam FO with caudal 35° beam
• close mouth
• open mouth
• clenched teeth

Remarks
5. Skeletal Survey
Skeletal Survey
 radiographic survey of the skeletal system
 series of radiographic projection
 demonstrate location of bone involvement by a pathological process, e.g. bone
metastasis
 varies with imaging centers

Common indications for SS

 infection (e.g. tuberculosis)
 malignant disease (e.g. bone metastasis)
 metabolic disease (e.g. rickets 佝僂病)
 endocrine disease (e.g. hyperparathyroidism)
 trauma (e.g. battered baby, i.e. non-accidental injury)

6. Contrast Study (Digestive System)

1. The schematic diagram shows the normal indentation of esophagus. Identify the
different normal indentation in the radiograph.
 Indication by aorta
 Indication by left bronchus
 Indication by left atrium

2. What is the possible diagnosis of this Barium swallow study?

 Oesophageal varices
 numerous rounded and elongated smooth-contoured filling defects are
present in the oesophagus
3. What is esophageal achalasia? How does Barium swallow study help the diagnosis of
esophageal achalasia?
 Esophageal achalasia: difficulty in opening the cardiac sphincter
 Real-time screening: assess the function of oesophageal in
emptying food into stomach

4. What is the possible diagnosis of this Barium swallow study?

 Oesophageal carcinoma
 shows irregular narrowing with ‘shoulder ends’
➜ suggestive a malignant stricture
A: Taper end (Beign) B: Shoulder end (malignant)

5. What is the possible diagnosis of this Barium swallow study? Can gastrografin be used in
this case? Why?
 Trachea-oesophageal fistula
➜ barium enhances the bronchial trees, and a connection is
demonstrated between tracheal and esophagus
 Gastrografin
➜ hydroscopic and will absorb the surrounding water in tissue
➜ result in pulmonary oedema

6. What is the possible diagnosis of this Barium meal study?

 Gastric ulcer
➜ en face view: pool of barium collecting in the ulcer crater on the dependent wall
with mucosal folds
 Ulcer appears as an outpouching from the gastric wall

en face view in profile view

7. What is the possible diagnosis of these Barium meal studies?
 Local infiltrating gastric carcinoma
➜ irregular narrowing affecting both lesser and greater curvature
 Diffuse infiltrating gastric cancer (linitis plastica)
➜ submucosal invasion

Polypoidal type
 soft-tissue mass causing a filling defect in the stomach
Ulcerating type
 the ulcerating area is confined to within the margin of the stomach
Local infiltrating type
 a focal area of mucosal irregularity and narrowing at the site of the tumor
Diffuse infiltrating type:
 diffuse submucosal infiltration with muscle invasion leads to a small rigid stomach
with poor distensibility: linitis plastica or 'leather hottle stomach.

8. In the slide, one of the radiographs shows the normal duodenal cap and the other
radiograph shows an abnormal duodenal cap. What is the possible abnormality?
 Duodenal ulcer

9. What is the possible diagnosis of this Barium meal study?

 Duodeno-biliary fistula
➜ connecting the bile ducts and duodenum
➜ barium spills into the bile ducts
10.What is the possible diagnosis of this Barium follow through study? In a Barium follow
through study, supine AP or prone PA abdominal radiograph can be taken. Discuss the
advantages and disadvantages of these two projections in the study.
 Intestinal obstruction
➜ bowel is distended
 AP:
✓easy to do the centering / patient would be more comfortable
✘higher radiation dose
 PA:
✓better radiation protection / display and spread the bowel away ➜ minimize the
overlapping of bowels / reduce of body thickness of abdomen ➜ lower radiation
✘difficult patient centering / patient may not feel comfortable

11.In barium enema examination, why the administration of barium usually starts with the
patient in prone and head down position?
 prone: barium can drain from rectum into the sigmoid more easily
 head down: from sigmoid colon to the descending colon by the means of gravity

12.In double contrast barium enema examination, why the barium infusion is terminated
when the barium reaches hepatic flexure?
 prevent excess amount of barium ➜ for coating the mucosa is enough ➜
demonstrate the abnormalities and better visualization ➜ fine lesion
 use gas to drain residue barium to the ascending colon

13.What is the possible diagnosis of this Barium enema study?

 Ca colon
 ➜ shouldering end / irregular narrowing / apple core sign
14.What is the possible diagnosis of this Barium enema study?
 multiple colonic diverticuli

15.What is the possible diagnosis of these two Barium enema studies?

 Crohn’s disease

7. Contrast Study (Urogenital System)

1. In an IVU examination, a supine KUB is the routine release film. When should an
additional prone / erect KUB film be taken? What is the significance of the prone / erect
KUB?
• Supine: contrast has difficulty flowing down the ureter
➜ suspected obstruction
Prone & Erect: by means of gravity
➜ kidney in high position
➜ contrast flows to the lower ureters and bladder
• Erect: rule out partial obstruction & complete obstruction
• Several deep breath: facilitate the flow of contrast
➜ eliminate any possibility that limit the flow of the contrast
➜ facilitate the flow of contrast
➜ if no contrast flow to the lower ureter and bladder ➜ severe ureter obstruction

Supine Prone Erect

2. As demonstrated in the radiograph, suggest the possible abnormality?
• Gall stone (NOT renal calculi)
• Oblique ➜ better understanding of the stone
whether it is in the kidney

3. In the radiograph, what is the difference in the urinary system of the patient when
compared to a normal condition?
• Bilateral duplex kidney (Unilateral = one side only)

4. Radiographs A, B and C show the radiological examinations performed on the same

patients. Identify the radiological examination of radiographs A, B and C. What is the
possible abnormality of the patient?
• A: KUB
➜ multiple stones in the left kidney and lower ureter

• B: IVU
➜ multiple stones in the dilated left ureter

• C: Retrograde Pyeloureterography
➜ a stenotic segment (black arrow) of the left lower
ureter above which is a dilated ureter packed with
stones
➜ Cystoscope
5. The radiographs were taken from the same patient. Identify the examinations where the
radiographs were obtained. What is the radiological abnormality and possible diagnosis?
• Coned Oblique KUB
➜ renal stone in left renal area

• Tomogram obtained in an IVU exam

➜ filling defects in the upper pole calyx and left renal
pelvis
➜ suggestive renal stone.
➜ Stones appear radiolucent against a background of
contrast.
➜ Note the distension of the minor renal calyx
➜ Blur out the bowel gas (out of the focal plane)

6. The radiographs were taken from the same patient. Identify the examinations where the
radiographs were obtained. What is the radiological abnormality and possible diagnosis?
• KUB
➜ renal stone in the left paravertebral region at L4

• Localized view of kidney in IVU

➜ hydronephrosis and calyces and dilated proximal ureter
➜ concentration of contrast is low
➜ contrast is diluted by urine in the upper ureter
➜ cannot demonstrate the ureter space occupying lesion
7. The radiographs were taken from the same patient. Identify the examinations where the
radiographs were obtained. What is the radiological abnormality and possible diagnosis?
• Antegrade pyelogram
➜ conducted by injecting contrast through percutaneous
nephrostomy catheter.
➜ bilateral hydronephrosis and dilated ureters
(hydroureter)
➜ contrast cannot go to the bladder
• Narrowing with tapered ends at the level of obstruction
➜ No contrast filling is found in the bladder
➜ bilateral ureteric obstruction
• Withdrawn resident urine by catheter
➜ radiopacity is high
➜ contrast will not be diluted

8. The radiographs were taken from the same patient. Identify the examinations where the
radiographs were obtained. What is the radiological abnormality and possible diagnosis?
• IVU (Full bladder view)
➜ feeling defect of a contrast filling urinary bladder
➜ bladder tumor
• Ureters are not shown
➜ drank a lot of water
➜ feeling of full bladder
➜ contrast eliminated from kidney and ureter to bladder
9. The radiographs were taken from the same patient. Identify the examinations where the
radiographs were obtained. What is the radiological abnormality and possible diagnosis?
• Plain X-ray
➜ radio-opaque in pelvic area
➜ bladder stone

• IVU (Oblique bladder view)

➜ filling defect in the contrast filled bladder
➜ bladder stone

8. Contrast Study (Hepatobiliary System)

1. Identify the radiological examination. Any abnormality you can identify?
• T-tube cholangiography
➜ stones within common bile duct (radiolucent)

2. A video of percutaneous transhepatic cholangiography (PTC) will be shown in the class.

From the video, can you find any antiseptic procedures? What is the significance of
these procedures?
• use the antiseptic solution (iodine) to clean patients’ skin
➜ prevent germs from entering the liver
• sterile gloves and PPE are used to avoid contamination of the wound
• the transducer and image intensifier are covered with sterile plastic bag
• blue cover is sterile to avoid other part of body is contaminated
➜ to avoid biliary sepsis
3. A video of percutaneous transhepatic biliary drainage (PTBD) will be shown in the class.
From the video, can you tell the significance of using the guide wire? Can you see where
the tip of the drainage catheter is placed?
• guiding the insertion of drainage catheter into the bile duct
• common bile duct

4. In a radiological examination of the biliary tract, doctor may put the patient in different
Trendelenburg positions (patient feet down or head down) after the administration of
contrast medium. What are the purposes of putting the patients in these positions?
• Head up: to allow the contrast to flow into the intrahepatic duct (see the patency)
• Head down: to allow the contrast to flow into the common bile duct and duodenum
(see the patency)

Trendelenburg head down position Trendelenburg feet down position

5. What are the objectives of Endoscopic Retrograde Cholangiopancreatography (ERCP)

examination?
Objectives
• Diagnosis of abnormalities in the biliary tract / pancreas
• Intervention of biliary tract
• Diagnosis: biliary tract stone

Diagnosis
• Biliary tract stenosis
• An inoperable carcinoma of the pancreatic head caused a
distal stenosis of the biliary duct
6. A video of endoscopic retrograde cholangiopancreatography (ERCP) will be shown in the
class. From the video, can you tell which equipment and techniques have been used?
• balloon canula
➜ remove the stone (balloon extraction of stone)
• sphincterotome
➜ open the opening of papilla (sphincterotomy)

Intervention for stone:

Basket cannula Balloon cannula

Intervention for stenosis (tumor):

• using a stent
7. A video of radiofrequency ablation (RFA) will be shown in the class. After watching the
video, can you tell:
i. How many percentages of patients with liver tumor can be treated with surgery?
• 15 – 30%
ii. Give one reason why a patient with liver tumor cannot be treated surgically.
• patient has multiple tumors at different sites
➜ the site is not suitable to do surgery
iii. What are the common imaging modalities used to guide the insertion of electrode?
• MRI / CT / US
iv. After RFA, the treated site will gradually be replaced by which kind of tissues?
• scar tissue

8. The photo shows the electrode commonly used for radiofrequency ablation of liver
tumor. What is the clinical significance in terms of the special outlook and design of the
electrode?
• increase the surface area of the tumor
• surround the tumor and cover a larger area