Self-assessment answers
Answer 1:
- “This is a supine AP abdominal radiograph of Mr CF. The radiograph is anonymised and therefore the date of the examination is unknown.”
“The hemi-diaphragms are included on this radiograph, however the pubic symphysis is not visualised. Ideally I would like to see the pubic symphysis.”
- “There is no evidence of free gas.”
- “The bowel gas pattern is within normal limits.”
- “There are multiple irregular foci of calcification (marked in yellow) projected over the midline in the mid-abdomen in the rough shape of the pancreas.”
- “There is no fracture or bony abnormality.”
- “There is no evidence of previous surgery, medical devices or any foreign body.”
“In summary, this is an abnormal abdominal radiograph showing pancreatic calcification.”
- Chronic calcific pancreatitis.
- The most likely underlying cause for chronic pancreatitis is alcohol abuse.
Answer 2:
- “This is a supine AP abdominal radiograph of Mr WC. The radiograph is anonymised and therefore the date of the examination is unknown.”
“The hemi-diaphragms are included on this radiograph, however the pubic symphysis is not visualised. Ideally I would like to see the pubic symphysis.”
- “There are branching dark lines projected over the liver (marked in dark blue), larger and more prominent towards the hilum of the liver.”
- “The bowel gas pattern is within normal limits.”
- “There is a rounded calcific density projected over the right upper quadrant (marked in yellow). Given the location this is likely to represent a calcified gallstone.”
- “There is a wedge fracture of L3.”
- “There are two short stents projected to the right of the midline in keeping with biliary stents.”
“In summary, this is an abnormal abdominal radiograph showing gas within the biliary tree (pneumobilia), a calcified gallstone, two biliary stents in situ and a wedge fracture of L3.”
- Indications include the following:
- Palliation or prevention of obstruction from gallstones within the bile duct.
- Palliation or relief of bile duct obstruction due to pancreatic malignancy.
- Recognised complications include the following:
- Perforation of the common bile duct or duodenum.
- Ascending cholangitis (infection).
- Pancreatitis.
Answer 3:
- “This is a supine AP abdominal radiograph of Mrs JV. The radiograph is anonymised and therefore the date of the examination is unknown.”
“The pubic symphysis and hemi-diaphragms are not visualised. Ideally I would like to see both hemi-diaphragms and pubic symphysis.”
- “There is no evidence of free gas.”
- “There is a ‘coffee bean’ shaped loop of distended bowel crossing the midline and extending to the right upper quadrant (marked in brown). There is a general lack of haustra within this loop. Further distended loops of bowel are noted in a peripheral location with haustra seen within.”
- “There is no abnormal calcification.”
- “There is no fracture or bony abnormality.”
- “There is no evidence of previous surgery, medical devices or any foreign body.”
“In summary, this is an abnormal abdominal radiograph showing a sigmoid volvulus with distension of the ascending, transverse and descending colon.”
- Elderly. There is almost always a history of chronic constipation.
- Assess the patient’s cardiovascular status and give intravenous (IV) fluids. Insert a flatus tube per rectum to decompress the dilated bowel.
Answer 4:
- “This is a supine AP pelvic radiograph of Mr JS. The radiograph is anonymised and therefore the date of the examination is unknown.”
“The pubic symphysis is included on this radiograph, however the hemi-diaphragms and upper abdomen are not visualised. Ideally I would like to see both hemi-diaphragms.”
- “There is no evidence of free gas.”
- “There is a loop of gas filled bowel (marked in green) projected over the left groin area below and lateral to the left obturator foramen and below the level of the inguinal ligament (marked in grey).”
- “There is no abnormal calcification.”
- “There is no fracture or bony abnormality.”
- “There is a urinary catheter in situ.”
“In summary, this is an abnormal abdominal radiograph showing a left groin hernia and urinary catheter in situ.”
- Large left inguinal hernia. Inguinal hernias are more common than femoral hernias in male patients.
- Possible correct answers include the following:
- Obstruction – If the herniated loop of bowel becomes trapped or tightly pinched at the point where it protrudes through the abdominal wall, the loop of bowel may become obstructed.
- Strangulation – Rarely, the hernia traps the bowel so tightly that the blood supply to the bowel is compromised. This is a serious complication and may lead to gangrene, bowel rupture, peritonitis and, if untreated, death.
Answer 5:
- “This is a supine AP abdominal radiograph of Mr RS. The radiograph is anonymised and therefore the date of the examination is unknown.”
“The hemi-diaphragms are included on this radiograph, however the pubic symphysis is only partially visualised. Ideally I would like to see the pubic symphysis.”
- “There is no evidence of free gas.”
- “The bowel gas pattern is within normal limits.”
- “There is a large dilated vascular structure in the midline with wall calcification seen (marked in red). It measures over 3 cm in diameter. There is also a well defined calcified opacity with a polygonal shape projected over the right upper quadrant in the region of the gallbladder (marked in yellow). A further area of linear calcification is seen projected over the left upper quadrant with a tortuous ‘Chinese Dragon’ like appearance outlining the splenic artery.”
- “There is degenerative change in the spine.”
- “There is no evidence of previous surgery, medical devices or any foreign body.”
“In summary, this is an abnormal abdominal radiograph showing an abdominal aortic aneurysm (AAA), a calcified gallstone projected over the right upper quadrant and degenerative change in the spine. Incidental splenic artery calcification noted.”
- >5.5 cm diameter. At this size the risk of aneurysm rupture outweighs the risk of operative management, and treatment is recommended.
Answer 6:
- “This is a supine AP abdominal radiograph of Mr NC. The radiograph is anonymised and therefore the date of the examination is unknown.”
“The pubic symphysis and hemi-diaphragms are not visualised. Ideally I would like to see both hemi-diaphragms and pubic symphysis.”
- “There is gas outlining both sides of the bowel wall (lumen of bowel marked in brown and free gas marked in turquoise) in keeping with Rigler’s sign.”
- “There are multiple centrally located gas-filled loops of bowel. Valvulae conniventes are seen in many of the loops and they measure >3 cm in diameter in keeping with dilated loops of small bowel.”
- “There is no abnormal calcification.”
- “There is no fracture or bony abnormality.”
- “There is no evidence of previous surgery, medical devices or any foreign body.”
“In summary, this is an abnormal abdominal radiograph showing a pneumoperitoneum and dilated loops of small bowel.”
- Bowel perforation.
- Assess the clinical status of the patient and resuscitate as necessary. Urgently refer the patient to the general surgeons. Give intravenous (IV) fluids, insert an NG tube and make the patient nil by mouth. Give broad-spectrum antibiotics and analgesia. If the patient is stable, consider a computed tomography (CT) scan to look for an underlying cause.
Answer 7:
- “This is a supine AP abdominal radiograph of Mrs VN. The radiograph is anonymised and therefore the date of the examination is unknown.”
“The pubic symphysis and hemi-diaphragms are not visualised. Ideally I would like to see both hemi-diaphragms and pubic symphysis.”
- “There is no evidence of free gas.”
- “The bowel gas pattern is within normal limits.”
- “There is abnormal calcification seen projected over the lower abdomen and pelvis with appearances in keeping with a fetus (marked in yellow). The spine of the fetus is seen to the right of the midline; lower limbs in the centre of the abdomen; upper limbs projected over the sacrum and the fetal skull in the pelvis.”
- “There is no fracture or bony abnormality.”
- “There is no evidence of previous surgery, medical devices or any foreign body.”
“In summary, this is an abnormal abdominal radiograph showing a fetus in situ.”
- The radiographer should have asked the patient if there is any chance she should be pregnant, and a pregnancy test should have been performed if the patient was unsure.
- Ultrasound scan of the abdomen to assess the foetus.
Answer 8:
- “This is a supine AP abdominal radiograph of Mrs MB. The radiograph is anonymised and therefore the date of the examination is unknown.”
“The hemi-diaphragms are not visualised and the pubic symphysis is only partially visualised. Ideally I would like to see both the hemi-diaphragms and the pubic symphysis.”
- “There is no evidence of free gas.”
- “The descending colon appears featureless with loss of the normal haustra giving a ‘lead pipe’ appearance (marked in green). There is also thickening of the bowel wall (marked in light green).”
- “There is no abnormal calcification.”
- “There is no fracture or bony abnormality.”
- “There is no evidence of previous surgery, medical devices or any foreign body.”
“In summary, this is an abnormal abdominal radiograph showing bowel wall inflammation of the descending colon with a ‘lead pipe’ appearance.”
- Inflammatory bowel disease
Ischaemic bowel
Infection
- Specific complications will vary depending on the underlying cause of the colitis. Possible correct answers include, but are not limited to the following:
- Intestinal perforation
- Severe bleeding per rectum
- Colonic strictures
Answer 9:
- “This is a supine AP pelvic radiograph of Mrs MH. The radiograph is anonymised and therefore the date of the examination is unknown.”
“The pubic symphysis is included on this radiograph, however the hemi-diaphragms are not visualised. Ideally I would like to see both hemi-diaphragms.”
- “There is no evidence of free gas.”
- “The bowel gas pattern is within normal limits.”
- “There is a large rounded area of calcification projected over the left pelvis with irregular areas of calcification within (marked in yellow). Appearances are typical of a calcified uterine fibroid.”
- “There is no fracture or bony abnormality.”
- “There is no evidence of previous surgery, medical devices or any foreign body.”
“In summary, this is an abnormal abdominal radiograph showing a large calcified uterine fibroid.”
- Uterine fibroid (uterine leiomyoma).
- Afro-Caribbean women (3× more common).
Answer 10:
- “This is a supine AP abdominal radiograph of Mrs KH. The radiograph is anonymised and therefore the date of the examination is unknown.”
“The hemi-diaphragms are not visualised and the pubic symphysis is only partially visualised. Ideally I would like to see both the hemi-diaphragms and the pubic symphysis.”
- “There is no evidence of free gas.”
- “There is a huge volume of faecal material extending from the pelvis to the left upper quadrant in keeping with a huge faecal impaction causing massive distension of the rectum (marked in brown).”
- “There is no abnormal calcification.”
- “There is no fracture or bony abnormality.”
- “There is no evidence of previous surgery, medical devices or any foreign body.”
“In summary, this is an abnormal abdominal radiograph showing a large faecal impaction.”
- In some patients the liquid stool passes around the obstruction (impacted faeces) giving paradoxical or overflow diarrhoea.
- Possible correct answers include the following:
- Ulceration or necrosis of rectal tissue
- Bowel incontinence
- Bleeding from anus
Answer 11:
- “This is a supine AP abdominal radiograph of Mr RR. The radiograph is anonymised and therefore the date of the examination is unknown.”
“The pubic symphysis is included on this radiograph, however the hemi-diaphragms are not visualised. Ideally I would like to see both hemi-diaphragms.”
- “There is no evidence of free gas.”
- “The bowel gas pattern is within normal limits.”
- “There are multiple small calcific densities projected to the left of the lumbar spine (marked in yellow). These are most likely in keeping with ureteric calculi as they are projected over the line of the left ureter. The term ‘steinstrasse’ (literally ‘stone street’) may be used for this appearance, which is often seen post-lithotripsy. A small calcific density is also projected over the lower pole of the left kidney in keeping with a renal calculus (also marked in yellow).”
- “There is no fracture or bony abnormality.”
- “There is a JJ stent in the left ureter (marked in purple).”
“In summary, this is an abnormal abdominal radiograph showing multiple left sided ureteric calculi, a small calculus at the lower pole of the left kidney and JJ stent in the left ureter.”
- Main indications:
- Relieve obstructive uropathy (e.g. obstructing renal calculus)
- Post surgery to allow healing of the ureter and prevent stricture formation
Answer 12:
- “This is a supine AP abdominal radiograph of Mrs AT. The radiograph is anonymised and therefore the date of the examination is unknown.”
“The pubic symphysis is included on this radiograph, however the hemi-diaphragms are not visualised. Ideally I would like to see both hemi-diaphragms.”
- “There is no evidence of free gas.”
- “The bowel gas pattern is within normal limits.”
- “There is no abnormal calcification.”
- “There is a large rounded soft tissue density in the left upper quadrant displacing loops of bowel inferiorly and medially (marked in red).”
- “There is no evidence of previous surgery, medical devices or any foreign body. Some tubing is seen projected at the edge of the radiograph on the right side, likely external to the patient.”
“In summary, this is an abnormal abdominal radiograph showing a large soft tissue mass in the left upper quadrant.”
- Splenomegaly or left renal mass are likely given the location.
- Ultrasound scan of the abdomen. This can be performed relatively quickly and does not involve ionising radiation. If ultrasound cannot diagnose the mass then a CT scan of the abdomen and pelvis with intravenous contrast is the next most appropriate investigation.
Answer 13:
- “This is a supine AP abdominal radiograph of Mrs NM. The radiograph is anonymised and therefore the date of the examination is unknown.”
“The pubic symphysis and hemi-diaphragms are not visualised. Ideally I would like to see both hemi-diaphragms and pubic symphysis.”
- “There is no evidence of free gas.”
- “There is a large loop of stomach shaped distended bowel in the upper abdomen (marked in light blue).”
- “There is no abnormal calcification.”
- “There is no fracture or bony abnormality.”
- “There is no evidence of previous surgery, medical devices or any foreign body.”
“In summary, this is an abnormal abdominal radiograph showing a gas filled dilated stomach.”
- Bowel obstruction (e.g. due to malignancy or due to scarring in the duodenum from peptic ulcer disease) or aerophagia (e.g. distressed patients or as a side effect of non-invasive ventilation).
- Stomach pylorus/proximal duodenum as the bowel distal to this point is not distended.
Answer 14:
- “This is a supine AP abdominal radiograph of Mrs MS. The radiograph is anonymised and therefore the date of the examination is unknown.”
“The hemi-diaphragms are not visualised and the pubic symphysis is only partially visualised. Ideally I would like to see both the hemi-diaphragms and the pubic symphysis.”
- “There is no evidence of free gas.”
- “There are multiple dilated loops of large bowel measuring over 5.5 cm in diameter with haustra seen within (marked in green).”
- “There is no abnormal calcification.”
- “There is no fracture or bony abnormality.”
- “There is no evidence of previous surgery, medical devices or any foreign body.”
“In summary, this is an abnormal abdominal radiograph showing multiple dilated loops of large bowel.”
- Correct answers include the following:
- Malignancy – Colorectal carcinoma is the most common cause of large bowel obstruction in adults.
- Diverticular structure
Other causes of large bowel obstruction include a volvulus (there is no evidence of a volvulus in this radiograph) and faecal impaction (there is no evidence of impacted faeces on this radiograph).
Answer 15:
- “This is a supine AP abdominal radiograph of Mr ST. The radiograph is anonymised and therefore the date of the examination is unknown.”
“The pubic symphysis and hemi-diaphragms are not visualised. Ideally I would like to see both hemi-diaphragms and pubic symphysis.”
- “There is no evidence of free gas.”
- “The bowel gas pattern is within normal limits.”
- “There are a few small calcific densities projected to the left and right of the lumbar spine (marked in yellow). The left sided calcific densities are projected over the lower pole of the left kidney and the right sided calcific densities are projected over the mid and lower pole of the right kidney.”
- “There is no fracture or bony abnormality.”
- “There is no evidence of previous surgery, medical devices or any foreign body.”
“In summary, this is an abnormal abdominal radiograph showing bilateral renal calculi.”
- Correct answers include (but are not limited to):
- Urinary tract infections (chronic)
- Hyperparathyroidism
- Hypercalciuria
- Cystinuria
- Anatomical anomalies (e.g. horseshoe kidney)
- Correct answers include (but are not limited to) the following:
- Extracorporeal shock wave lithotripsy (ESWL)
- Percutaneous nephropyelolithotomy
Answer 16:
- “This is a supine AP abdominal radiograph of Mrs EA. The radiograph is anonymised and therefore the date of the examination is unknown.”
“The pubic symphysis is included on this radiograph, however the hemi-diaphragms are not visualised. Ideally I would like to see both hemi-diaphragms.”
- “There is no evidence of free gas.”
- “There are multiple centrally located gas-filled loops of bowel (marked in blue). Valvulae conniventes are seen in many of the loops and they measure >3 cm in diameter in keeping with dilated loops of small bowel.”
- “There is no abnormal calcification.”
- “There is no fracture or bony abnormality.”
- “There is no evidence of previous surgery, medical devices or any foreign body.”
“In summary, this is an abnormal abdominal radiograph showing dilated loops of small bowel.”
- Mechanical small bowel obstruction secondary to adhesions (most common in the UK).
- ‘Drip and suck’. Drip = give intravenous (IV) fluids, suck = insert nasogastric (NG) tube and make the patient nil by mouth. Urgently refer the patient to the general surgeons. Consider a CT scan to look for an underlying cause. If the bowel obstruction does not resolve within 24–28 h, surgery may be required.
Figure 181: Mrs EA. Taken on unknown date. Abdominal pain and vomiting for 24 h (annotated).