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Introduction to Radiology. Michael Solle, MD, PhD. Introduction to Radiology. I: Radiology Basics and High Yield Topics Modalities in Radiology and Cases Contrast How to look at studies Catheters: tunneled vs non-tunneled Drains and Tubes II: How to Consult Radiology

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introduction to radiology

Introduction to Radiology

Michael Solle, MD, PhD

introduction to radiology2
Introduction to Radiology
  • I: Radiology Basics and High Yield Topics
    • Modalities in Radiology and Cases
    • Contrast
    • How to look at studies
    • Catheters: tunneled vs non-tunneled
    • Drains and Tubes
  • II: How to Consult Radiology
  • III: Plain Film Imaging of the Abdomen
  • IV: Parting Thoughts
  • Dr. Molina and Chest Radiology
definition of radiology
Definition of Radiology
  • Radiology is a medical specialty using medical imaging technologies to diagnose and treat patients.
i basics hi yield radiology modalities
I: Basics/Hi-Yield:Radiology Modalities
  • Conventional radiographs (“x-rays”)
    • Fluoroscopy
    • Mammography
  • Computed Tomography (CT)
  • Nuclear Medicine (NM)
      • PET-CT combines CT and NM
  • Ultrasound (US)
  • Magnetic resonance imaging (MRI)
radiology modalities
Radiology Modalities
  • Conventional Radiography
    • Lingo:
      • Density
      • Opacity
  • Observable Densities:
    • Metal
    • Bone
    • Soft Tissue
    • Gas
radiology modalities6
Radiology Modalities
  • Fluoroscopy
    • “Live” imaging
    • Contrast agents often given
radiology modalities7
Radiology Modalities
  • Computed Tomography
    • Lingo:
      • Attenuation
      • Density
      • Enhancement
  • Hounsfield Units
      • -1000 air ***
      • -100 fat
      • 0 water ***
      • 20-80 soft tissues
      • 100’s bone/Ca/contrast
      • >1000’s metal
  • Large radiation dose
radiology modalities8
Radiology Modalities
  • Nuclear Medicine
    • Lingo:
      • Counts or Activity
  • Physiologic imaging
    • Radionuclides
      • Technetium
    • Radiopharmaceuticals
      • “Choletec”
  • Radioactivity stays with the patient until cleared or decayed
radiology modalities9
Radiology Modalities
  • Ultrasound
    • Lingo
      • Echogenicity
      • Shadowing
      • Doppler for flow
  • No radiation
  • Can be portable
  • Relatively inexpensive
radiology modalities10
Radiology Modalities
  • MRI
    • Lingo:
      • Signal intensity
      • T1
      • T2
      • Enhancement
  • No radiation
  • Strong magnetic field
      • No pacemakers
      • No electronic implants
  • Small, loud tube and patients must be able to hold still
  • Relatively expensive
radiology modalities11
Radiology Modalities:
  • Four different cases of Abdominal Pain
  • Can you develop a differential diagnosis based location of the abdominal pain?
  • Can you identify the modality used?
  • Diagnosis?
i radiology modalities summary
I: Radiology Modalities Summary:
  • Conventional radiographs (“x-rays”):
      • Great place to start (cheap, fast, low radiation).
  • Computed Tomography (CT):
      • Diagnostic dilemmas (pricier, variable speed b/c of contrast).
      • High radiation.
  • Nuclear Medicine
      • Physiological imaging, great for specific questions.
  • Ultrasound (US)
      • Relatively inexpensive, and no radiation.
      • Highly dependent on patient’s body size and US operator.
  • Magnetic resonance imaging (MRI)
      • Relatively expensive, no radiation, not fast.
      • Unmatched ability to contrast healthy tissue from disease.
i basics hi yield a few words on contrast
I: Basics/Hi-Yield:A few words on contrast
  • CT contrast:
    • IV- contains Iodine; which attenuates x-rays
      • Contraindicated in renal failure (acute and chronic) b/c of risk of contrast induced nephropathy
      • Allergy issues
      • Power injected and causes vaso-vagal reactions (NPO)
    • PO- contains dilute iodine or sometimes very dilute barium (flouro studies typically use barium)
  • MRI contrast:
    • IV- contains gadolinium chelated to a carrier molecule; acts as a paramagnetic molecule which increases signal on T1 images
      • Contraindicated in renal failure (acute and particularly ESRD) b/c of risk of NSF
i basics hi yield a few words on contrast18
I: Basics/Hi-Yield:A few words on contrast
  • AVOIDING CONTRAST IN THE SETTING OF ACUTE RENAL FAILURE IS DIFFICULT for the radiologist, because the creatinine may be normal.
  • In hyper-acute renal failure, the creatinine hasn’t risen yet. Decreased urine output or anuria is acute renal failure – regardless of the creatinine.
  • Remember; first do no harm! Non-contrast studies can often be quite helpful.
i basics hi yield looking at imaging studies
I: Basics/Hi-Yield:Looking at Imaging Studies:
  • Adequate Study?
    • Correctly labeled with patient’s name, MR#, and the date of the study?
    • Technically adequate?
  • Systematic versus Focused look at a study:
    • Radiologist does both!
    • As the requesting clinician, you should also look at your patient’s study (at least plain films), as well as follow up on the final report.
      • PTX, PNA, pleural effusions, SBO, free air
      • Evaluate lines and tubes (especially the ones you placed!)
i basics hi yield looking at imaging studies20
I: Basics/Hi-Yield:Looking at Imaging Studies:
  • PACS workstations (diagnostic versus clinical)
      • Picture Archiving and Communications System
      • Radiology, ER, ICU’s, some surgery clinics
  • Web based PACS (web 1000)
  • WebCIS based PACS (java script)
      • At UNC: “6-PACS” is PACS help desk
i basics hi yield tunneled versus non tunneled catheters
I: Basics/Hi-Yield:tunneled versus non-tunneled catheters
  • First, examine the patient!
    • Inspect
    • Palpate
    • (Don’t auscultate or percuss)
  • A tunnel is a short (several inches) segment of catheter that is within the superficial soft tissues (subcutaneous fat) between the venotomy site and the catheter access site.
    • “Perm Caths”
    • “PortaCaths”
    • “Powerlines”
  • A tunnel or port pocket infection usually means removal of the line.
  • CVAD= central venous access device
i basics hi yield tubes drains abscesses g neph
I: Basics/Hi-Yield:tubes & drains (abscesses, G-, Neph-)
  • Most VIR drains/tubes need to be flushed with sterile saline.
      • The purpose of this is simply to keep the tubes from getting clogged. All tubes should be flushed after use.
      • There’s usually a 3-way stopcock to accomplish this.
  • Nephrostomy and Gastrostomy tubes need to be changed every 3 months or so.
  • Abscess drains usually need a sinogram (tube injection) to evaluate the cavity size and for any fistulous connections, about 2 weeks after placement.
      • If cavity small and output of drain is low, then drain may be pulled. If it’s pulled too early, then the abscess will fester/return.
  • Surgical drains are managed by the surgical teams, and often do not need to be flushed (no 3-way stopcock).
ii obtaining a radiology consult
II: Obtaining a Radiology Consult
  • A Radiology consult is obtained every time a study is requested!
  • Who handles these requests and reads these studies and/or performs these procedures?
ii obtaining a radiology consult25
II: Obtaining a Radiology Consult
  • The Department of Radiology at the University of North Carolina at Chapel Hill has eight clinical sections:
    • Abdominal Imaging (Body CT, US, MRI, Flouro studies such as UGI and SBFT, Biopsies)
    • Breast Imaging
    • Cardiopulmonary Imaging (Chest, Cardiac)
    • Musculoskeletal Imaging (Bone, ER RR, MSK MRI’s)
    • Neuroradiology (brain/spine CT & MRI; lumbar punctures)
    • Nuclear Medicine (wide variety, PET-CT, bone scans, Cards)
    • Pediatric Imaging (wide variety)
    • Vascular-Interventional (wide variety)
ii obtaining a radiology consult26
II: Obtaining a Radiology Consult
  • 6-1461- The Radiology “Front Desk”
  • Reading rooms (RR’s):
    • Body CT 3-2938
    • Chest 3-2939
    • GI/Adult Flouroscopy 3-2961
    • Neuroradiology 3-2978
    • Pediatrics 6-7554
    • MSK/bone 6-8850
    • US 6-0038
    • MRI 6-8112
    • Mammography 6-6392
    • Nuclear medicine 3-2937
    • VIR 6-4645
ii obtaining a radiology consult at unc hospitals
II: Obtaining a Radiology Consult (at UNC Hospitals)
  • Try to call the right reading room (RR).
    • When you call, identify yourself, and expect whoever answers to identify themselves.
      • Improves accountability
      • Good policy to know who you talked to (always)
  • When paging, it’s nice to put your name/pager number immediately after the call back number
  • After hours:
      • 6-8850 Lower Level/ER RR
      • 216-2826 Upper Level (VIR, Doppler US, MRI)
  • DON’T call 6-8850 during the day
      • unless it’s an MSK radiology issue
ii obtaining a radiology consult30
II: Obtaining a Radiology Consult:
  • VIR or any other invasive procedures:
    • Who gives consent? Pleae get phone number of HC POA or spouse or relative
    • Basics for any invasive procedure
      • See the patient!
      • Coags (PT, PTT, INR)
      • Platelets
      • NPO for sedation or GA
    • Don’t promise the Bx/Line/procedure, but please tell the patient before we get there…..
    • Don’t promise sedation (but we almost always use it)
  • Think about risks/benefits prior to considering invasive or expensive procedures. Ask yourself if the results will change management.
iii plain film imaging of the abdomen
III: Plain film imaging of the abdomen
  • Stones
      • Gallstones
      • Renal stones
  • Bones
      • Lumbar spine, pelvis, hips
  • Masses
      • Organomegaly, ascites
  • Gasses
      • 3 cm small bowel
      • 6 cm large bowel
      • 9 cm cecum
iii plain film imaging of the abdomen33
III: Plain film imaging of the abdomen
  • KUB (kidneys, ureters, bladder)
  • 2 View---AP supine and erect abdomen
  • Acute abdomen series: 2 view with upright chest
  • Lateral decubitus (Left or Right)
  • Cross table lateral---prone or supine
iv a few random parting thoughts
IV: A Few Random Parting thoughts
  • Patients want a doctor who cares about them. When admitting a patient, get their (family’s) phone numbers yourself, as part of the History and Physical.
    • Patients will forgive you for a host of small things if you show them that you care, will be honest with them, you will work hard for them over the long term.
    • Getting their phone numbers show you care about them and their family.
  • Learn to take ownership of your patient’s and their medical problems.
    • Follow up on test/imaging results.
    • Follow up on clinical outcomes.
  • Longitudinal data is often the most valuable information there is.
    • “Old is gold.”- in reference to getting prior imaging studies.
    • Serial KUB’s and serial exams is often more clinically relevant than getting a CT scan.