INVESTIGATION

RADIOLOGY
& CLINICAL PATHOLOGY
TABLE OF CONTENTS
I. RADIOLOGY
Introduction 3
Ethics of radiology 23
Basics of radiology 28
Chest imaging 136
Bone & Joints X-Rays 197
Radiology of GI tract 275
Genitourinary system imaging 352
Hypercalcemia cases 403
Radiology of the brain 415
Radiology of the spine 472

II. CLINICAL PATHOLOGY

CBC ,Inflammatory and immune markers 499
Kidney / Elyctrolytes / ABG 531
Liver enzymes and viral markers 571
DM ,Lipid & hormonal tests 592

INV
Introduction
Department of diagnostic and interventional radiology

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Imaging
modalities
• Imaging modalities
classified into
❑ Ionizing radiation:
🞄 X-Ray
🞄 M SC T
🞄 Interventional radiology
🞄 Nuclear medicine
🞄 Fluoroscopy

❑ Non-Ionizing radiation:
🞄 MRI( magnetic resonance
imaging)
🞄 US(Ultrasonography)
X-Ray
X-rays are the oldest and most used
medical imaging technique. X-rays were
discovered in 1895 and first used to image
human tissue in 1896. X-rays use ionizing
radiation to produce images of internal
structure by sending beams through the
body. These are absorbed at different levels
depending on the density of the tissue.

X-ray radiation can generate three kinds of

medical images; conventional X-ray
imaging, angiography and fluoroscopy.
Indications of x-
ray
• Conventional X-ray imaging generates
an image of a localized part of the
body, which will be analyzed for
anatomical abnormalities.
This kind of imaging usually
evaluates:
• The skeletal systems: bone
• The oral cavity (bone and teeth)
• Any ingested objects: foreign bodies
• The lungs: chest x-ray
• The breast (Mammography)
• The digestive system, e.g. intestinal
obstruction
Computed tomography
• C T is a diagnostic imaging technique
that uses x-rays and computer
processing to create detailed cross-
sectional images of the body. It's
commonly used to diagnose and
monitor various medical conditions
and can also guide minimally invasive
procedures. C T scans involve exposure
to ionizing radiation, so healthcare
providers must ensure they're
medically necessary and minimize
radiation exposure.
Indications of CT
• C T S C A N S A R E O F T E N U S E D TO
EVALUATE:
• Organs in the pelvis, chest and abdomen
• Colon health (CT colonography)
• Presence of tumors
• Pulmonary embolism (CT angiography)
• Abdominal aortic aneurysms (CT
angiography)
• Spinal injuries
• Cardiology.
Ultrasound
• Here are benefits of ultrasound:

• Ultrasound is a safe and effective procedure that is often used in

conjunction with other imaging modalities, such as X-rays and MR I. It is a
valuable tool for healthcare providers and can help them diagnose and treat
a variety of conditions.

🞄 It is portable and can be used in a variety of settings, including the

doctor's office, the hospital, and the bedside.
🞄 It is relatively inexpensive and can be used to screen large populations for
diseases.
🞄 It is real-time, which means that images can be seen as they are being
created. This can be helpful in diagnosing conditions that change quickly,
such as heart problems.
🞄 It is non-invasive, which means that it does not require surgery or sedation.
Indications of Ultrasound
• Abdomen and pelvis: Ultrasound can be used to assess
the organs in the abdomen and pelvis, diagnose conditions
such as gallstones, kidney stones, liver disease,
and cancer, and guide procedures such as biopsies and
drainages.

• Gynaecology and obstetrics: Ultrasound can be used

to assess the health of the female reproductive system,
diagnose pregnancy, and monitor the development of a
fetus.

• Musculoskeletal system: Ultrasound can be used to

assess the muscles, tendons, ligaments, and joints, diagnose
conditions such as muscle strain, tendonitis, and arthritis,
and guide procedures such as injections and aspirations.

• Thyroid: Ultrasound can be used to assess the thyroid

gland, diagnose conditions such as thyroid nodules and
thyroid cancer, and guide procedures such as biopsies.

• Heart: Ultrasound can be used to assess the structure and

function of the heart, diagnose heart conditions, and
monitor the effects of treatment.

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Magnetic
resonance
imaging
• M R I uses a powerful magnetic field,
radio waves and a computer to
produce detailed pictures of internal
body structures. M R I does not use
radiation (x-rays).

• Detailed M R images allow doctors to

examine the body and detect
disease. The images can be reviewed
on a computer monitor. They may
also be sent electronically, printed
or copied to a C D , or uploaded to a
digital cloud server

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Indications of
MRI
• M R imaging is usually the
best choice for examining
the:
• major joints.
• spine for back pain.
• soft tissues (muscles,
tendons and ligaments) of
the extremities.
Interventional
Radiology
• often guided by
imaging technology
such as X-ray, C T scan,
or ultrasound.

• provide targeted
treatments for a range
of conditions, including
vascular diseases,
cancer, and pain
management. They use
their expertise to
navigate the body's
complex network of
blood vessels and organs
to reach the affected
area and deliver the
necessary treatment.

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Indications of
Interventional
Radiology

1. Hematemsis & hemoptysis

2. Trauma(pelvic hematoma)
3. Ischemia (stroke)
4. Coiling of cerebral
aneurysm
5. Radiofrequency ablation of
hepatic focal lesions ,thyroid
nodules and bone tumors
6. TACE(management of
liver tumors)

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 Positron
emission
tomography

PET CT

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Positron emission tomography
• Positron emission tomography (PET) scans are useful
in the detection of cancer.
• They are particularly useful in determining whether
lesions that are visible on a C T scan of the chest are
malignant or benign.
• Cancer is typically associated with the
increased uptake of fluorodeoxyglucose.
• PET scanning is used after chemotherapy to assess for
the presence of residual cancer in some patients and can
also be used to determine whether a patient is an operative
candidate to remove a primary cancer.
• If the PET scan does not reveal malignancy, then the
resection of certain primary cancers, such as lung
cancer, is more likely to be successful.
PET-C T preparation
• Always check the patient’s glucose
before doing a PET scan. If the
glucose is elevated, the PET scan
can be falsely negative.
• Remember that slow-growing
cancers
• (e.g., bronchoalveolar) may
have a negative PET scan. Be
careful when evaluating
pulmonary nodules with PET This Photo by Unknown author is licensed under C C B Y .

scanning.
Ethics in
Radiology

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Medical necessity:
When to request imaging
• Radiologic procedures involve
exposing patients to ionizing
radiation, which can have
harmful effects on their health.
Therefore, healthcare providers
have an ethical responsibility to
ensure that any imaging
test ordered is medically
necessary and will provide
important diagnostic or
therapeutic information.
Ordering unnecessary tests
exposes patients to unnecessary
radiation and can result in
increased healthcare costs.
Informed
consent
• Obtaining informed consent
from patients is a critical
component of ethical
imaging pr actice.
Healthcare providers have a
responsibility to explain
the risks, benefits, and
alternatives of any imaging
test to the patient and obtain
their consent before
proceeding.

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Confidentiality
• Radiology staff have an ethical
responsibility
to mai ntai n the confidentia
li ty of pati ent information.
Healthcare providers
must ensure that all patient
information is protected and
only released to
authorized i ndi viduals.

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Radiation
safety
• Radiation safety: Healthcare
providers have
a responsibility to mi ni mi ze ra
diation exposure to patients
and staff.

• Radiologic procedures
must be performed in accordance
with established radiation safety
guidelines to mi ni mi ze the risk
s associated wi th i oni zing
radi ation exposure.
Basics of Radiology
Examples of different Imaging Modalities
1-X-ray
2-CT scan
3-MRI
4-Ultrasound
5-Others:
-ECHO
-Isotope Scan
-DEXA
X-ray Musculoskeletal
Basics
1-Please identify the bone
2-Please identify the side: Lt or Right
3-Please identify the lesion
Chest X-ray
CT chest
 CT of the CHEST
• Mediastinal window; Important landmarks:
1. Superior vena cava (Formed by right and left brachiocephalic veins).
2. Aortic arch branches: Left subclavian – Left common carotid –
Brachiocephalic artery.
3. Aortic arch, Ascending Aorta, and Descending Aorta.
4. Pulmonary trunk and branches (Right and left)
5. Then, every vessel goes into the corresponding cardiac chamber;
• Superior vena cava goes into right atrium
• Pulmonary artery into right ventricle
• The chamber with thick wall is Left ventricle
• The most posterior chamber is Left atrium)
 CT of the CHEST
• Lung window; Important landmarks:
❖It is very important to determine the level of the section you are
examining.
1. When you see the trachea, this means that you are at the upper lung
lobes.
2. When the trachea is divided, the section is divided (Anterior parts
represent the upper lobes and posterior parts represent the lower
lobes).
3. When you are at the heart level, the section is divided into anterior
third (Lingula, at the left side and lower lobe at the right side). Both
posterior two thirds represent the lower lobes
Left to right: Aortic arch (Left) Aortic arch divided into Ascending and
1. Left subclavian artery SVC (Right) descending aorta. Note the beginning of the
2. Left common carotid artery pulmonary trunk.
3. Brachiocephalic artery

Pulmonary trunk divided into Right and Left SVC → Rt. Atrium. Four chambers of the heart (from Right to
branches. Pulmonary trunk → Rt. Ventricle. left): Rt. Atrium – Rt Ventricle – Left ventricle
(Thick wall) – Left atrium (Most posterior).
Trachea is seen as a single tube, Trachea is divided, At the heart level, the section is divided
then the section is in the upper lung The section is divided. into:
lobes Anteriorly: Upper lobes. Anterior third;
Posteriorly: Lower lobes • Right side: Middle lobe
• Left side: Lingula.

Posterior two thirds:

Right and left: Lower lobes.
CT Pelvi-Abdomen
Brain Imaging
The next section denoting normal CT Brain .
Please notice normal brain anatomy.
Please notice the red arrow denoting the level of the cut.
Different cuts of MRI Brain
 CHEST IMAGING
BY
INVESTIGATIVE MEDICINE STAFF
FACULTY OF MEDICINE
MODERN UNIVERSITY FOR TECHNOLOGY AND INFORMATION
 AGENDA

•Chest X-Ray (CXR)

•Computed tomography (CT) of the Chest
 CHEST X-RAY
• Principle
• Indications…
• Contraindications
• Advantage
• Disadvantages
• Normal study
• Important landmarks:
1. Tracheal air column
2. Ribs/Clavicle
3. Lung fields
4. Bronchovascular markings
5. Diaphragmatic copula
6. Costophrenic/Cardiophrenic angles
7. Cardiac size, chambers, and major vessels)
• Common abnormalities (Pneumonia – Pleural effusion – Pneumothorax – Pulmonary nodules –
Cardiomegaly).
• How to comment..??
 TECHNICAL ASPECTS OF NORMAL FILM
QUALITY:
• Standard x- rays are based on the degree of density of tissue and how
• much x- ray energy each type of tissue will absorb:
• The basic five radiographic densities: Gas-Fat-Fluid-Bone-Metal.
• The closer a bone structure is in density, the greater the energy it will
• absorb. Therefore, because bones block the most amount of x-ray
• energy they will come out white on the film.
• Conversely, air absorbs or blocks the least amount of energy and thus
• will appear darkest.
 Technical quality of
CXR film:
When examining a chest x-ray, first assess the film for
its technical quality.
► Orientation.
► Rotation
 ORIENTATION

Most x-rays are posterior-anterior (PA) films. The x-ray plate is placed in front of
the chest, and the patient leans forward against the plate. The x-ray beam is
directed from posterior to anterior. The patient must be able to stand for a PA
film to be performed.
Anterior-posterior (AP) films are less accurate but must be done if the patient is
too ill or unstable to stand up; such as patients with central venous lines or
chest tubes or those in intensive care.
Lateral chest x-ray will determine whether a structure in the chest is more
anterior or posterior. For example, it can determine whether a mass that is
visible in the center of the mediastinum on a PA film is posterior, making it more
likely to be a neurally derived tumor attached to the spinal cord or an anterior
mass. Anterior mediastinal masses are from the thymus, thyroid, lymph
nodes, or a teratoma
 CHEST X-RAY; INDICATIONS:
• Chest radiography is the most basic radiologic examination and often the
initial one
• diagnostic study performed to evaluate patients with respiratory symptoms:
• breathing difficulties, a bad or persistent cough, chest pain or injury and
fever.
• It may also be the initial evidence of pulmonary disease in a patient
without
• symptoms, e.g., the pulmonary nodule found on an incidental x-ray.
 CHEST X-RAY; INDICATIONS:
• Infection: Pneumonia, Tuberculosis
• Trauma: Pneumothorax and haemothorax
• Assessment of:
1. Chest pain: exclude pneumothorax, perforated viscus, aortic dissection
2. Dyspnoea: exclude heart failure, pleural effusion interstitial lung disease
3. Haemoptysis
• Suspected malignancy, metastasis or lymphadenopathy
 CONTRAINDICATIONS

•Pregnancy
ADVANTAGE
CHEST X-RAY; NORMAL:

Postero-anterior view
CHEST X-RAY; NORMAL:

Lateral view
 CHEST X-RAY; NORMAL:

Postero-anterior view Lateral view

The cardiothoracic ratio: A+B/C
Normally <0.5
 CHEST X-RAY;
HOW TO COMMENT..
• Plain X-ray of chest and heart.
• Postero-anterior/Lateral view.
• Position of mediastinum.

• Costophrenic angles (Free/Obliterated).

• Cardiothoracic ratio

• Diaphragm; Normally:

1. Right copula (overlying the liver) higher than the left copula.
2. Dome in shape, smooth surface, and convex upwards.
 CHEST X-RAY;
HOW TO COMMENT..
• Lung fields:
1. Bronchovascular markings
(Normal/Increased/Decreased/Absent)
 Increased in bronchitis
 Decreased/Absent in pneumothorax

2. Abnormalities:
 Site
 Lobe/Zone (Upper/Middle/Lower)
 Laterality (Unilateral/Bilateral)

 Size (in cm.)

 Shape (Rounded/Oval/Triangular/Fluffy-cotton)
 CHEST X-RAY;
COMMON ABNORMALITIES:
Patient with cough, expectoration, and fever

PNEUMONIA Consolidation

Consolidation

Right middle lobe pneumonia Left lower lobe pneumonia

 CHEST X-RAY;
COMMON ABNORMALITIES:

Patient with long standing history of Chronic obstructive pulmonary disease

Jet black
appearance

RIGHT PNEUMOTHORAX
RIGHT PNEUMOTHORAX
RIGHT PNEUMOTHORAX
 CHEST X-RAY;
COMMON ABNORMALITIES:

Patient with long standing history of peptic ulcer disease

PNEUMOPERITONEUM

Air under diaphragm

CHEST X-RAY;
COMMON ABNORMALITIES:

Patient with shortness of breath

PLEURAL EFFUSION

Note the obliteration of the right costophrenic angle

LEFT PLEURAL EFFUSION
CHEST X-RAY;
COMMON ABNORMALITIES:

Patient with long standing history of cough, weight loss, and night sweats

Multiple right-sided pulmonary nodules

Note the multiple rounded variable-sized opacities

BILATERAL MULTIPLE LUNG MASSES
CHEST X-RAY;
COMMON ABNORMALITIES:

Patient with shortness of breath and edema of both lower limbs

CARDIOMEGALY
 COMPUTED TOMOGRAPHY (CT)
OF THE CHEST
• Indications..
• Contraindications
• Advantages
• Disadvantages
• Orientation
• Important landmarks (Mediastinal window..! and Lung window..!)
• Contrast or no contrast
• Common abnormalities (Pneumonia – Pleural effusion – Pneumothorax – Pulmonary nodules)
 CT OF THE CHEST; INDICATIONS:

Same indications of Chest X-Ray; In addition to:

1. Equivocal CXR
2. Malignancy staging and evaluation (Pulmonary/Cardiac/Mediastinal).
3. Mediastinal: Aortic aneurysm – Aortic dissection – Pulmonary embolism.
4. Cardiac and pericardial abnormalities: Calcification (Constrictive
pericarditis).
5. Pulmonary and pleural abnormalities: Pneumonia – Fibrosis – Bronchiectasis
– Nodules – Pleural (Effusion, empyema, hemo/pneumothorax).
 CONTRAINDICATIONS
• Renal impairment or dye hyper sensitivity in CT with contrast
• Pregnancy
 ADVANTAGES
• 1.high image resolution
• 2.more accurate for quantitative and qualitative measure of body
composition and lesions
• 3.detect bone ,soft tissue, blood vessels at the same time
• 4.noninvasive ,fast ,simplE and accurate
• 5.Can be performed if there is implanted device unlike MRI
 DISADVANTAGES
• High dose of radiation
• Risk of malignancy from excessive exposure to radiation
• Morbid obese patients may not fit into the opening of conventional CT
Scanner or over the weight limit for the moving table
• Not recommended for pregnant women or children except medically
necessary
• Side effects of contrast as renal affections or hypersensitivity
 CT OF THE CHEST; ORIENTATION:
Patient’s front, Anterior
• With or without
contrast
• Lung or mediastinal
window

• Any air is black.

More dense tissue RIGHT LEFT
appears white
(Hyperdense).

Patient’s back (Bed), Posterior

Axial CT scan of the chest Coronal CT scan of the chest

MEDIESTINAL WINDOW
LUNG WINDOW
Left to right: Aortic arch (Left) Aortic arch divided into Ascending and
1. Left subclavian artery SVC (Right) descending aorta. Note the beginning
2. Left common carotid artery of the pulmonary trunk.
3. Brachiocephalic artery

Pulmonary trunk divided into Right and SVC  Rt. Atrium. Four chambers of the heart (from Right
Left branches. Pulmonary trunk  Rt. Ventricle. to left): Rt. Atrium – Rt Ventricle – Left
ventricle (Thick wall) – Left atrium (Most
posterior).
Trachea is seen as a single tube, Trachea is divided, At the heart level, the section is
then the section is in the upper The section is divided. divided into:
lung lobes Anteriorly: Upper lobes. Anterior third;
Posteriorly: Lower lobes • Right side: Middle lobe
• Left side: Lingula.

Posterior two thirds:

Right and left: Lower lobes.
 CT OF THE CHEST;
CONTRAST OR NO CONTRAST:
Intravenous contrast required

• Malignancy workup and follow-up may require contrast to

delineate hila, chest wall, vascular margins, or recurrent or
Iodine-based contrast materials injected residual tumor.
into a vein (intravenously) are used to • Suspected or known malignancy or infection of chest wall or
enhance x-ray (including fluoroscopic mediastinum
images) and CT images. Gadolinium • CT pulmonary angiography for pulmonary embolism or arterio-
injected into a vein (intravenously) is venous malformation
used to enhance MR images. • CT pulmonary venography for superior vena cava syndrome
Intravenous contrast usually not required

• Solitary pulmonary nodule

• Pulmonary parenchyma, to evaluate for infection, inflammation,
edema
• Interstitial lung disease
• Pleural effusion
• Airway assessment
CT OF THE CHEST;
COMMON ABNORMALITIES:
Patient presenting fever with cough for 5 days

Pneumonia
CT OF THE CHEST;
COMMON ABNORMALITIES:
Patient presenting shortness of breath

Bilateral pleural effusion

CT OF THE CHEST;
COMMON ABNORMALITIES:
Patient presenting shortness of breath

Right sided pneumothorax

LUNG ABCESS
LUNG ABCESS
RIGHT PULMONARY NODULE
RIGHT PLEURAL EFFUSION
BILATERAL PLEURAL EFFUSION
 CT CHEST;
EXAMPLES:

Peripheral area of ground-glass opacity in Bilateral pleural effusion with scattered Left pneumothorax
right lower lung lobe. pulmonary nodules.
Multiple, bilateral, well-circumscribed A nodule in the upper left lobe with Ground-glass opacity in the left
pulmonary nodules. irregular margins lower lobe.
Large pulmonary cavity CT findings in
with an air-fluid level keeping with the
within the left mid zone plain film
(Lung abscess). appearances,
demonstrating a
large cavity within
the left lower lobe,
with an air-fluid
level within.
BONE & JOINTS
X- RAYS
 CONTENTS
i. Systematic approach for interpretation of
orthopedic x-rays.
ii. Viewing principles of orthopedic x-rays.

iii. Fractures overview.

iv. Upper limb x-rays.

v. Lower limb x-rays.
vi. Axial skeleton x-rays.

vii. DEXA scanning.

SYSTEMATIC CHECKLIST
For orthopedic x-rays
• Although the system for viewing X-rays

of bones and joints varies depending on

the anatomy being examined, there are

some broad principles which can be

applied in a number of situations.
 Systematic checklist
Patient and image details

Bone and joint alignment

Joint spacing

Cortical outline

Bone texture

Soft tissues
 Systematic checklist

Patient and image details

• Start by checking you are looking at the correct
image.

• Check patient's details, date and time of the X-

ray noted.

• The skeletal system is symmetrical, so it’s

particularly important to be sure you are looking
at the correct side.
Systematic checklist

Bone and joint alignment

• Loss of alignment may be due to a bone

fracture or a joint dislocation.

• Both are associated with soft tissue

injury that may not be directly

visualized.
 Bone and joint alignment
Loss of bone alignment at the middle toe
metatarsophalangeal joint due to dislocation
Systematic checklist

Joint spacing

• Joint spacing may be narrowed due to

cartilage loss or widened due to
dislocation/dissociation.
 Joint spacing
Osteoarthritis of the 1st metatarsophalangeal joint
Note also the large osteophytes - a sign of
osteoarthritis
Systematic checklist

Cortical outline
• Careful scrutiny of the bone cortex is

required in order to reach a complete

diagnosis.
 Cortical outline
Fractured ring finger metacarpal bone - a so
called 'boxer's fracture'
Systematic checklist

Bone texture
• In some bones a fine matrix or fine white

lines (trabeculae) is seen.

• Occasionally bone injury or disease will

result in abnormality of this texture.

 Bone texture
Proximal femur
Well defined trabecular pattern visible forming the
femoral neck architecture
Systematic checklist

Soft tissues
• Scrutinizing the soft tissues can often provide

helpful information.

• Not uncommonly an abnormality of soft

tissues is more obvious than a bone injury, or
may even imply a bone injury that is not
visible at all.
 Soft tissues
Tibial plateau fracture
Joint effusion containing fat and blood that has
leaked from bone following trauma
VIEWING PRINCIPLES
For orthopedic x-rays
 Viewing Principles
2 views are better than 1

Check all available images

Compare with the other side (if

imaged)

If available ALWAYS compare with

old X-rays
 2 views
Oblique fracture of the distal fibula at the level of
the ankle joint
 Compare with the other side
Fractured neck of right femur
 Compare current with previous images
Metastatic disease of bone with pathological
femoral shaft fracture
FRACTURES
overview
 Language Of Fractures

• Important for use to describe x-rays in

medical terminology and to improve

communication with consultants.
Language Of Fractures

• Things you must describe (clinical and x-

ray):

Open versus closed fracture.

Anatomical location of the fracture.

Fracture line.

Relationship of fracture fragments.

Neurovascular status.
Open versus Closed Fractures
Open Closed
Compound Simple

Cutaneous (open No open wounds of

wounds of skin) skin)

Either complete displaced

or comminuted
 Anatomical Location
• Describe the precise anatomic location
of the fracture.

• Include if it is right or left sided.

• Include name of bone.

• Include location: proximal…mid….distal

part of bone.
Fracture Lines
Types of Fracture Lines
A TRANSVERSE FRACTURE

B OBLIQUE FRACTURE

C SPIRAL FRACTURE

D COMMINUTED FRACTURE
 Neurovascular Status
• When facing a fracture, it is important to

describe if the patient has any

neurological deficit.

• This is to be determined by clinical

examination.
UPPER LIMB
X-RAYS
 Clavicle - Normal
intact cortex
 Clavicle - Fracture
Transverse/oblique mid shaft fracture
Inferior displacement of the distal clavicle
 Shoulder joint- Normal AP view
The humeral head and glenoid contours are
aligned normally.
 Anterior shoulder dislocation – AP view
Humeral head and glenoid surfaces are not aligned
The humeral head lies below the coracoid.
 Humerus fracture – Shaft
Pathological fracture of humeral shaft
 Elbow joint- Normal AP & Lateral view
 Elbow - Supracondylar fracture
 Wrist bones - Normal X-ray (PA)
 Bones of the hand - Normal X-ray (PA)
 Rheumatoid arthritis- x ray both
hands
LOWER LIMB
X-RAYS
 Hip joint X-ray anatomy - Normal AP
 Hip X-ray anatomy - Normal AP

• Shenton's line is
formed by the medial
edge of the femoral
neck and the inferior
edge of the superior
pubic ramus
• Loss of contour of
Shenton's line is a sign
of a fractured neck of
femur
 Intracapsular fracture - Subcapital - AP
 Subtrochanteric fracture
This fracture passes distal to the trochanters
The femoral neck remains intact
 Hip dislocation - AP
 Femoral shaft fracture
Spiral fracture with posterior angulation, lateral
displacement and shortening
 Knee joint - Normal AP
 Tibial and fibular fracture
Comminuted fractures of the tibial and fibular shafts
with medial displacement and posterior angulation
 Ankle joint anatomy - Normal AP
 Lateral malleolus fracture - AP
Transverse fracture of fibular tip with soft tissue
swelling
 Foot X-ray anatomy – Dorsal Plantar
and Oblique views
 Metatarsal shaft fracture

• Oblique fracture of the

5th Metatarsal shaft
• Fracture more clearly
visible on the oblique
image
AXIAL SKELETON
X-RAYS
 Axial Skeleton
Skull Cervical
spine
Ribs Sternum

Lumbar Pelvis
spine
 Skull – Normal - Lateral view
 Skull - Normal - AP view
 Skull fractures - AP

• The black lines

represent skull
fractures
• These lines are too
smooth to be sutures
and do not branch like
the vascular markings
of the skull
 C-spine - Normal Lateral view
 C-spine systematic approach
• Coverage - All vertebrae are visible
from the skull base to the top of T2

• Alignment - Check the Anterior line (the

line of the anterior longitudinal ligament),
the Posterior line (the line of the posterior
longitudinal ligament), and the
Spinolaminar line (the line formed by the
anterior edge of the spinous processes -
extends from inner edge of skull)

• - GREEN = Anterior line

• - ORANGE = Posterior line
• - RED = Spinolaminar line

• Bone - Trace the cortical outline of all

the bones to check for fractures
 C-spine systematic approach
• Disc spaces:The vertebral
bodies are spaced apart
by the intervertebral discs -
not directly visible with X-
rays. These spaces should be
approximately equal in height

• Pre-vertebral soft tissue:

Some fractures cause
widening of the pre-
vertebral soft tissue due to
pre-vertebral haematoma
 Rib fractures
Multiple displaced lower left rib fractures are
visible
 Thoracic spine - Lateral and AP
 Spinous process fracture - Lumbar
spine – Lateral view
 Pelvis anatomy - Normal AP view
DEXA ??
BMD MEASUREMENT
(BONE MINERAL DENSITY)
Dual-energy x-ray absorptiometry (DEXA) scan is an x-ray used to
measure bone mineral density (BMD)
 Sites of assessment
Lumbar Spine
• To flatten the lordosis of the lumbar spine, the patient
lays supine with their hips and knees flexed on a
supportive cushion.
• BMD measurements are obtained using the L2-L4
vertebral bodies.
Hip
• The patient lies supine and use a positioning device
which internally rotates the femur to elongate the
femoral neck.
• BMD measurements are obtained using neck density.
Forearm
• The patient’s non-dominant arm is placed on the table
with the forearm pronated.

Whole Body
• The patient is placed supine on the table with arms
pronated and feet in dorsiflexion.
HOW TO INTERPRET ??
 T- score

> -1 -1 to >-2.5 ≤ -2.5

Normal osteopenia osteoporosis

Z- score
If ≤ -2

Secondary osteoporosis
 Normal Dexa scan
 Normal Dexa scan
 Primary Osteoporosis
 Secondary Osteoporosis
 Osteopenia
Indications of bone x-ray?
• diagnose fractured bones or joint dislocation.
• demonstrate proper alignment and stabilization of bony fragments
following treatment of a fracture.
• guide orthopedic surgery, such as spine repair/fusion, joint
replacement and fracture reductions.
• look for injury, infection, arthritis, abnormal bone growths and bony
changes seen in metabolic conditions.
• assist in the detection and diagnosis of bone cancer.
• locate foreign objects in soft tissues around or in bones.
What are the limitations of bone x-ray?
• While x-ray images are among the clearest, most detailed views of bone, they
provide little information about muscles, tendons or joints.
• An MRI may be more useful in identifying bone and joint injuries (e.g.,
meniscal and ligament tears in the knee, rotator cuff and labrum tears in the
shoulder) and in imaging of the spine (because both the bones and the spinal
cord can be evaluated). MRI can also detect subtle or occult fractures or
bone bruises (also called bone contusions or microfractures) not visible on x-
ray images.
• CT is being used widely to assess trauma patients in emergency
departments. A CT scan can image complicated fractures, subtle fractures or
dislocations. In elderly or patients with osteoporosis, a hip fracture may be
clearly seen on a CT scan, while it may be barely seen, if at all, on a hip x-ray.
Radiology of
GI Tract
Investigative medicine
Abdominal X – Ray :

 Indications of plain abdominal x-Ray :

 Suspected bowl obstruction
 Suspected perforation
 Suspected foreign body
 Moderate to severe undifferentiated abdominal pain
 Renal tract calculi
• Contraindications :

 Pregnancy is a relative contraindication to the use of ionizing radiation (it is

of obsolete contraindication in the 1st trimester and of relative
contraindication in the 2 and 3 trimesters)
nd rd

• non-ionizing studies (e.g. ultrasound or MRI) should be tried first

• abdominal radiographs (x-ray) administer a much lower radiation dose than
CT
Projections
Normal abdominal x ray
How to assess the X-ray film?

 Identify the sides correctly and inspect the liver and spleen shadows.
 Bilateral renal outlines should be present and symmetric and smooth.
 Right kidney is lower than left.
 Bilateral psoas shadows should be symmetric.
 Urinary bladder may or may not be outlined depending on the degree of
distention.
 Visualized bony structures should be inspected for abnormality.
 Identify normal bowel gas pattern.
Gas distribution :

 Stomach
 Small intestine :
 Large intestine :
Comment includes:

1. Bowel gas pattern Large and small bowel

2. Abnormal gas collections(extraluminal gas) free gas (gas under diaphragm),
bowel wall gas, Biliary gas, retroperitoneal gas
3. Bones.
4. Soft tissues and Viscera Liver, spleen, kidneys
5. Abnormal calcification Gall stones, renal tract , pancreas, vascular
6.Retroperitoneum and abdominal wall Psoas lines, abdominal wall muscles and
peritoneum
Large intestinal obstruction
Perforation in X Ray
Foreign body in X ray
Barium studies
 Barium Studies

 These studies are specialized x-

ray procedures using a solution
containing barium to examine
the gastrointestinal tract,
namely the esophagus,
stomach, small intestine and
large intestine.
 The most common studies are
barium swallows, barium meals
and barium enemas.
Types of barium studies :

 Barium swallow (Esophagus)

 Barium Meal (Esophagus and Stomach)

 Barium Follow through (Small intestine)

 Barium enema (colon)

 Barium swallow
 Barium swallow is a dedicated test of the pharynx, esophagus, and
proximal stomach, and may be performed as a single or double contrast study.

Indications:
❖ High or low dysphagia
❖ gastro-esophageal reflux disease (GERD)
❖ assessment of a hiatus hernia
❖ generalized epigastric pain
❖ globus pharyngeus
❖ persistent vomiting
❖ assessment of fistula
❖ inability to pass the endoscope during UGIE
Contraindications
Water-soluble contrast agents should be used instead of barium sulfate in the
following cases:
• suspected perforation
• postoperative assessment for leak

Examination technique depends on the indication of the study.

Preparation needed for study is overnight fasting, avoiding smoking or
chewing gum to decrease the secretions in the oral cavity and pharynx
normal barium swallow mass effect from thyroid nodule luminal narrowing
Irregularity looks like an apple core lesion in the esophagus.
This is typical in carcinoma of the esophagus
Cancer Esophagus
Achalasia

 The esophagus has

smooth contour and
is narrowed conically
at the esophago-
cardiac junction
(arrow), above this
the distal part of the
esophagus is dilated
 Achalasia with
bird's beak
deformity of
the distal
esophagus
Barium Meal MEAL
Barium meal and follow-through
Barium enema
Barium enema
Colonic diverticulosis
Ultrasound
 Ultrasound, also called
sonography, uses sound
waves to develop ultrasound
images of what's going on
inside the body.
 An instrument called a
transducer emits high-
frequency sound, inaudible
to human ears, and then
records the echoes as the
sound waves bounce back to
determine the size, shape,
and consistency of soft
tissues and organs.
 Types of Ultrasound
 Most ultrasounds are done using a transducer on the surface of the skin.

 In a transvaginal ultrasound, a transducer wand is placed in a

woman’s vagina to get better images of their uterus and ovaries.
 A transrectal ultrasound is sometimes used in the diagnosis of prostate
conditions.
 A transesophageal echocardiogram uses the transducer probe in
the esophagus so that the sonographer can obtain clearer images of
the heart.
Additionally, ultrasound technology has
advanced to allow for different types of
imaging:
• Doppler is a special type of ultrasound that creates images
of blood flow through vessels.
• Bone sonography helps diagnose osteoporosis.
• Echocardiograms are used to view the heart.
• 3D imaging adds another dimension to the ultrasound
image, creating three-dimensional interpretations rather
than the flat two-dimensional images that are made with
traditional ultrasound.
• 4D ultrasounds show 3D images in motion.
 Benefits of Ultrasound
• They are generally painless and do not require needles,
injections, or incisions.

• Patients aren't exposed to ionizing radiation.

• Ultrasound captures images of soft tissues that don't show up

well on X-rays.

• Ultrasounds are widely accessible and less expensive than

other methods.
  Point A: Right Upper Quadrant
Right mid- to anterior axillary line at the 8–10th
intercostal space. What can be evaluated: right
hemidiaphragm, liver, pleural effusion, ascites, right
kidney, IVC, and aorta.
 Point B: Subcostal Point
Common structures to be evaluated: IVC, aorta,
pancreas, liver, gallbladder, common bile duct, ascites,
and stomach.
 Point C: Left Upper Quadrant
Left mid-axillary line at the 8–10th intercostal space.
Picture of a Common structures to be evaluated: left
transducer (probe) hemidiaphragm, spleen, left kidney, and ascites.
used during an
ultrasound exam.
 Point D: Suprapubic Window
Structures to be evaluated: bladder, prostate gland,
uterus, and ascites.
Red arrows :
dilated
intrahepatic
bile ducts

Red arrowheads
: blood vessels
Liver cirrhosis
Gall bladder stone
CT pelviabdomen
Normal CT abdomen
Pneumoperitoneum
Gall bladder stones
 Renal
Stones
Renal stone
Liver cirrhosis

Normal liver
Renal tumors
 Focal liver disease

Hydatid cyst
Hydatid disease is a worldwide zoonosis produced by
the larval stage of the Echinococcus tapeworm

Simple cyst

Hepatic metastasis

Hepatocellular
carcinoma
 Chronic pancreatitis
 CT shows calcifications
and pancreatic
pseudocyst
Investigational Medicine
Genitourinary system
imaging
By / Dr. Marwa Shaaban
Agenda

 Plain X-ray of urinary tract

 INTRAVENOUS UROGRAPHY (IVU)
 Voiding/Micturating cystourethrogram
 Ultrasound of genitourinary system
 CT scan of genitourinary system
 Magnetic resonance urography (MRU) of genitourinary
system
Anatomy of the urinary system:
 Plain X-ray of urinary tract
 Indication:
❖ Taken to evaluate the urinary tract before other diagnostic procedures.
❖ useful in visualizing calcification anywhere along the urinary tract.
 Patient position:
❖ Supine, lying on the back on x-ray table.
❖ Xray taken with full inspiration, this cause diaphragm to contract, allowing all renal contents
to visualized on single image.
❖ Preparation: We use laxative, the night before the test to clear colon of solid fecal material.
On good quality film psoas muscle should be visible.
Comment on
❖ Soft tissue shadows (kidneys, Psoas lines)
❖ Radio-opaque shadows (stones, calcifications)
❖ Bones (vertebrae, ribs, bony pelvis)
❖ Gas distribution
Projections
KUB
 RADIOOPAQUE SHADOW

Renal stones
Stone in the urinary
Ureteral stones
▪
▪ Nephrocalcinosis ▪
bladder or in a
Ureteric catheter bladder diverticulum
▪ Calcified renal cyst or ▪

tumor ▪ Calcified mass in the

▪ Calcified wall of urinary bladder
▪ Calcified Urinary ureter
Lower end ureteral stone
bladder
▪
 Urolithiasis
Refers to the presence of calculi (stones), anywhere along the
course of the urinary tract
⚫ PUT will detect:(opaque)
⚫ calcium stones 75%
⚫ Struvite 15%
⚫ cystine stones 1%

⚫ PUT will miss: (lucent)

Bilateral lower ureteric stones
⚫ uric acid stones 5-8%
⚫ small stones
⚫ stones obscured by bones

Urinary bladder stone

Stag horn stone
Large kidney stones that fill the renal
pelvis and at least one renal calyce.
Most of the time they are composed of
struvite (magnesium ammonium
phosphate), recurrent urinary tract
infections by urease-producing
pathogens.
 Nephrocalcinosis

 characterized by the deposition of

calcium salts in the kidney
parenchyma and tubules.
Nephrocalcinosis may cause acute
or chronic kidney injury or be
incidentally detected
radiographically in a patient with
normal kidney function.
Calcified renal cyst

Ureteric stent
Lower-end ureteric stone
Prostatic calcification
Intrauterine device (IUD) in female.

UB calcification: bilharziasis, radiation cystitis,

tumor, TB.
 INTRAVENOUS UROGRAPHY (IVU)
 Shows anatomy and functions of the kidneys:
Demonstrates both function and structure of the
renal system •Function ---→ Filtration
•Structure ---→ Contrast filled collecting system
 After injection of IV contrast, it concentrates in the
kidneys. Excreted by kidneys and pass via ureters
into the urinary bladder.
 We take a series of films to follow the passage of
contrast from the kidneys to the urinary bladder.
 Contrast Shows renal parenchyma, collecting
system, and ureters.
 Evaluate urothelial abnormalities, haematuria,
urolithiasis.
 Preparation
⚫ Renal function
⚫ Bowel preparation (e.g. laxatives , castor oil)
⚫ Fasting (4-6hs)
⚫ Sensitivity

Principles :
▪ Patient preparation + empty bladder.
▪ Initial PUT (control film).
▪ IV contrast (Bolus method or Infusion method)
▪ Nephrographic phase: immediately.
▪ Pyelographic phase: within 5-15 min
▪ Cystogram: within 20- 30 min
▪ Post micturition
▪ Follow up films up to 24 hours (if there is delayed excretion).
 IVU
 Indications:
• Urolithiasis/calculus
•Pyelonephritis
•Hydronephrosis
•Trauma
•Tumour
•Renal hypertension
•Congenital abnormality
 Contra-Indications: (relative)
•History of Allergy
•Asthma, Contraindications to x-ray
and
Normal anatomy of PCS in IVU
 KUB vs IVU
I-Control film: detect any radiopaque
stone or shadow or calcification:
II- Normal nephrogram (60-
III- Normal pyelogram (5-15min): For
90sec):To visualize renal
parenchyma and outline for detection of any obstruction within the
masses pelvicalyceal system(PCS).
IV- Normal bladder cystogram (20-30 min)

Post micturition film: shows bladder emptying

 Horse-shoe kidney:-
Duplex collecting system:- It exists when the lower pole of the kidneys are fused
Characterized by an incomplete fusion during development.
of upper and lower pole moieties
resulting in a variety of complete or
incomplete duplications of the
collecting system.
Left upper third Ureteric
stone (arrow) with subsequent Pelvi-ureteric junction (PUJ) obstruction:
uretero-hydronephrosis Intrinsic:
proximally. ▪ In the lumen (stone, blood clot, FB)
▪ In the wall (distal stricture, edema, tumor)
Extrinsic (compression or invasion by external mass, fibrosis)
vesicoureteral reflux
URINARY BLADDER TUMORS
(Malignant filling defect)

Benign enlargement of the prostate (BPH)

(Benign filling defect) : Smooth dome-like
indentation along the floor of the bladder .
 Voiding/Micturating cystourethrogram
 Fluoroscopic study of the lower urinary tract in which
contrast introduced into the bladdervia a catheter.
 Functional and anatomical evaluation of bladder and urethra
especially posterior urethra.
 Commonly for kidneys with recurrent UTI
 Dx.reflux, urethral valve, ureterocele, urethral stricture, and
diverticula
 Scout film Pediatric 6-8F catheter. For adult standard
catheter
 Technique:
▪ Patient empties the bladder before examination.
▪ A urinary catheter is inserted into the bladder.
▪ Contrast medium is slowly dripped or infused through the
catheter into the bladder.
▪ Intermittent screening of the patient on fluoroscopy, while
distending bladder...To check for ureterocele or VUR.
▪ After the bladder is filled, the catheter is removed and the
patient is now asked to void.
Normal ACUG Normal voiding urethrogram
Vesicoureteric reflux
 Ultrasound
It is the most common method used in urinary system
examination
Indications:
❖Detection of renal stones in the renal pelvis and calyces, as well as UB and
vesicoureteric stones.
❖Detection of hydronephrosis.
❖Detects renal cysts and uterine lesions.
❖Detects renal and bladder masses.
❖Detection of small and scarred kidneys in advanced chronic renal disease.
❖ Detects perinephric collection and abscess.
❖ Allows measuring the post-void residual urine volume.
❖ Detection of benign prostatic hyperplasia with measurement of
prostatic volume.
❖ Detects ovarian torsion.
❖ Renal duplex ultrasound allows diagnosis of renal artery stenosis, and ovarian
torsion and differentiates between epididymo-orchitis and testicular torsion
advantages: Available No
radiation Good anatomy
disadvantage: Operator
dependent
Kidney stones Kidney stone
small or scarred kidneys

A-Simple Renal cyst

Complex renal cysts: show turbid content, calcification, septae, thick wall or
soft tissue component
- Due to either infection, hemorrhage, or malignancy on top
UB masses

UB stones
 Prostatic enlargement :
compressing urinary bladder

Enlarged prostate
compressing
urinary bladder
with measurement
of its volume.
Post-voiding bladder volume measurement: After urination (voiding)
there should be no more than 50 ml of urine left in the bladder).
prostate or bladder outflow disease
 CT scan
 Gold standard test: It is a quick non-invasive technique for diagnosis
 With and without contrast Standard CT technique for renal imaging.
 IV contrast differentiates pathological processes from normal ones. Parenchyma,
corticomedullary differentiation.
 Non-contrast helical CT shows any kind and small size of stone (It is usually
considered now as the initial imaging modality for suspected urolithiasis in an
emergency setting),
Indication:
1- suspected urolithiasis.
2- Hematuria.
3- Flank pain.
Technique: Patient position: supine with his arm above his head.
Scan extent: From above the kidney to below the symphysis pubis.
 Normal kidneys

Hyper-dense→ white (stone/bone)

Hypo-dense grey to black (fat/fluid)
Adv.: Relatively available (more
then MRI) Very good anatomy Upper third right ureteric stone with
disadv.: Radiation Some times subsequent mild right hydronephrosis
need IV contrast (? reaction)
MSCT KUB….With right renal Right ureteric stone with subsequent
stone right hydroureteronephrosis and left
lower calyceal stone
 CT IV pyelography ( MSCT urography):
heterogenous density right renal mass
MSCT KUB…….urinary bladder
stone
MSCT urography……strictureof left
ureter (arrow), with subsequent
proximal dilated ureterand
hydronephrosis of left kidney Left renal hydronephrosis with
marked left renal pelvis dilatation,
suggesting PUJ stricture.
Contrast enhanced MSCT…..heterogeneously enhancing soft
tissue mass seen at right lateral wall of urinary bladder
MSCT contrast revealed soft
tissue mass inside ureteric lumen
in MSCT urography the ureteric
mass seen as filling defect
Magnetic resonance urography (MRU)

 Hyper-intense (white) Hypo-intense (grey to

black)
▪ Radiation free-way to look at structure and function of
the urinary tract, mainly used during pregnancy and in
cases of sensitivity to MSCT contrast media.
▪ Main indications:-
➢ To demonstrate the level of obstruction in a poorly
functioning kidney or urinary system obstruction.
➢ Congenital abnormalities of the urinary system.
Normal MRI and MRU
Ureteric stricture
Horse shoe kidney
Right Duplex collecting system
HYPERCALCEMIA CASES
Dr.Dina Marawan
Associate professor of endocrinology
Click to edit Master title style
• Edit Master text styles
PART 1
• Second level
• Third level
Radiology of the B r ain
• Fourth level
• Fifth level
Radiology Modalities:
❖ Computed Tomography (CT):

CT scanner
 CT imaging:

• In standard brain CT without

contrast, imaging is taken in the
axial plane.
• Post processing re-formats the
image into sagittal and coronal
images.

Scout for CT showing

axial sections planning
(Oblique dotted lines)
Graphic illustration of Axial - sagittal- coronal planes
showing different brain sections in these planes.
 CT imaging:

• On viewing the CT
images, the patient’s
right is on the left side
of the display monitor.
 CT imaging:
•Uses the (Hounsfield Unit scale) (HU) to assign densities to tissues
Hounsfield Units range from -1000 (air) to +1000 (metal) with 0 assigned to
water

• We use ‘density’ for description

• The white is hyperdense.
• The black is hypodense.
• Isodense is the intermediate signal.
• In case of IV contrast study: We describe the presence or absence of enhancement.
 CT imaging:

• There are basic standard settings:

(as : Bone, Brain, Angio-window)
for image display, however any
other specified level/window
setting can be adjusted on the
monitor while reviewing the
scan.

A B
• Patients are imaged once, and
we just adjust the window
parameters to display the A: Head CT visible on brain level and window. Bone not well seen
B: Head CT on bone level and window. Brain not well seen
specified window.
Image courtesy Dr. Brent Burbridge, University of Saskatchewan
CT cerebral angiography:
• It is used for vessel imaging such
as the intra-cranial arteries, and
cervical arteries looking for
pathologies like aneurysms,
narrowing, occlusion, or
dissection, etc.
• IV contrast is injected.
• The image acquisition can be
timed to maximally enhance
arteries or veins (CT
arteriography- CT venography).
Advantages of CT Brain
• CT is much faster than MRI, making it the study of choice in
cases of trauma and other acute neurological emergencies
especially in hemorrhage
• CT is less sensitive to patient motion during the examination.
because the imaging can be performed much more rapidly
• CT provides detailed evaluation of bone, detection of
calcification and metal foreign bodies
• CT can be performed to patients with MRI contraindications
such as cardiac pacemakers, and cochlear implants or in
claustrophobic patients
Radiology Modalities:

❖ Magnetic Resonance Imaging (MRI)

Closed MRI machine

Advantages of MRI

• It provides outstanding soft-tissue contrast that is superior to

that obtained from CT.
• MR can be performed with or without intravenous contrast
agents.
• It does not employ ionizing radiation and has no known
permanent harmful biologic effects.
MRI terms :
In MRI we use the following terms for description:
• High signal intensity = hyperintense = white
• Intermediate signal intensity = isointense =grey
• Low signal intensity = hypointense = black
How to easily differentiate between
CT from MRI brain study?

Bone is bright in CT while is dark in MRI

Look for skull bones
 CT brain images showing
Hyperdense (white) bony structures “red arrows”

A: Head CT visible on brain level and window. Bone details not well seen
B: Head CT on bone level and window. Brain not well seen
Yet the bone is hyperdense (white) in both images

Image courtesy Dr. Brent Burbridge, University of Saskatchewan

 MRI:

Axial T2 weighted image of the brain:

• Green arrow represents the
subcutaneous fat not the skull bones.
• Red arrow represents the low signal
(hypointense or dark) of the outer table
of the skull bone
• Yellow arrow represents the high signal
of the fatty bone marrow present within
the skull bone
 In MRI ( intensity )
If any fluid ( CSF, vitreous ,..) appears dark ( hypointense) ➔ it T1 WI “WI= weighted image”
And if it appears bright ( hyperintense ) ➔ T2 WI

Axial T2 weighted image of the brain (at the level of the Axial T2 weighted image of the brain (at the level of the
lateral ventricle): cerebellum):
Yellow arrow represents the hyperintense signal of the Green arrow represents the hyperintense signal of the
CSF within the ventricles and subarachnoid space. eye globe vitreous.
 MRI:

• T2 weighted (T2 WI) sequences:

The dominant signal intensities of different tissues are:
• Fluid (e.g. CSF): high signal intensity (white)
• Fat: high signal intensity (white)
• Brain parenchyma:
white matter is darker than grey

Axial T2 weighted image of the brain at the

level of the basal ganglia and lateral ventricle
 MRI:
• T1 weighted (T1 WI) sequences:
• They are the most anatomical of images, resulting
in images that closely approximate the
appearances of tissues macroscopically
• The dominant signal intensities of different tissues
are:
• Fluid (e.g. CSF): low signal intensity (black)
• Fat: high signal intensity (white)
• Brain parenchyma:
grey matter is darker than the white
matter

Axial T1 WI of the brain at the level of basal ganglia

 Fluid (CSF) in CT and MRI

• CSF is bright “hyperintense ” in MRI T2 weighted image (WI) (left hand side image)
• CSF is dark “ hypointense” in MRI T1WI (middle image)
• CSF is dark “ hypodense” in CT (right hand side image)
 MRI:
MR angiography (MRA)
• It is an alternative to
CT angiography
• No radiation exposure
• Non-invasive evaluation of the
cerebral vessels
• There are:
• Contrast enhanced MRA
• Non-contrast enhanced
MRA

MRA TOF (non-contrast enhanced technique) 3 D image

for intracerebral arteries (Image courtesy of A. Osborn)
Note:

When describing the signal brightness of a structure:

• In CT, we use the word density
• In MRI, we use the word intensity

• Bone is hyperdense in CT but hypointese in MRI

• Any normal body fluid in CT is hypodense
• but fluid in MRI, if it is T1WI ➔ hypointense ,
if it is T2WI ➔ hyperintense
IMPORTANT SECTIONS OF BRAIN ANATOMY

BRAIN CSF SPACES VASCULAR

Cerebrum
Ventricular
system ARTERIAL
Cerebellum
VENOUS
Sulci and fissures
Brain stem
Brain parenchyma and
lobar anatomy
Fissures
• The fissures are large CSF-
filled clefts which separate
structures of the brain
• The interhemispheric
fissure separates the
cerebral hemispheres the
two halves of the brain

• The Sylvian fissures

separate the frontal and
temporal lobes

Axial CT images of the brain

https://www.radiologymasterclass.co.uk/tutorials/ct/ct_brain_anatomy/ct_brain_anatomy_ventricles
• Falx cerebri
The falx is an in folding of the
meninges which lies in the
midline and separates the left
and right cerebral hemispheres

• Tentorium cerebelli
An infolding of the dura mater
forms a tent-like sheet which
separates the cerebrum
(brain) from the cerebellum
https://www.radiologymasterclass.co.uk/tutorials/
ct/ct_brain_anatomy/ct_brain_anatomy_meninges
Axial CT images of the brain
https://www.radiologymasterclass.co.uk/tutorials/ct/ct_brain_anatomy/ct_brain_anatomy_meninges
Axial CT images of the brain
https://www.radiologymasterclass.co.uk/tutorials/ct/ct_brain_anatomy/ct_brain_anatomy_meninges
Grey matter and white
matter
• The white matter is located
centrally and appears darker
than the grey matter in CT
images due to its relatively
low density

Axial CT images of the brain

https://www.radiologymasterclass.co.uk/
tutorials/ct/ct_brain_anatomy/ct_brain_a
natomy_lobes
 Basic grey matter
structures
• Cortex
• Insula
• Basal ganglia and thalamus

Axial CT images of the brain

https://www.radiologymasterclass.co.uk/tutorials/ct/ct_brain_anatomy/ct_brain_anatomy_grey_matter
 Axial T2 WI of the brain at the level of the basal ganglia

https://radiologyassistant.nl/neuroradiology/brain/anatomy
Basic white matter structures
*White matter of the brain lies deep
to the cortical grey matter.

*The internal capsules are white

matter tracts which connect with
the corona radiata and white matter of
the cerebral hemispheres superiorly,
and with the brain stem inferiorly.

* The corpus callosum is a white

matter tract located in the midline. It
arches over the lateral ventricles and
connects white matter of the left and
right cerebral hemispheres.
https://www.radiologymasterclass.co.uk/tutorials/ct/ct
_brain_anatomy/ct_brain_anatomy_white_matter
Basic white matter structures
*White matter of the brain lies deep
to the cortical grey matter.

*The internal capsules are white

matter tracts which connect with
the corona radiata and white matter of
the cerebral hemispheres superiorly,
and with the brain stem inferiorly.

* The corpus callosum is a white

matter tract located in the midline. It
arches over the lateral ventricles and
connects white matter of the left and
right cerebral hemispheres.
https://www.radiologymasterclass.co.uk/tutorials/ct/ct
_brain_anatomy/ct_brain_anatomy_white_matter
Radiologic anatomy of the brain:

❖ Lobar anatomy:
Radiologic anatomy of the brain:
❖Lobar anatomy and
boundaries:
Frontal lobe is separated from the
parietal lobe by the central sulcus

Case courtesy of Dr Azza Elgendy,

Radiopaedia.org, rID: 33667
Radiologic anatomy of the brain:
❖Lobar anatomy and
boundaries:
• The Sylvian fissure/ the lateral
sulcus separates the frontal from
the temporal lobes.
• The insular cortex is located
immediately deep to the Sylvian
fissure.

https://www.stepwards.com/?page_id=23176
Radiologic anatomy of the brain:
❖Lobar anatomy and
boundaries:
• The parieto-occipital
fissure or sulcus
demarcates the occipital
lobe from the parietal lobe
on the medial surface of
the cerebral hemisphere.
https://www.stepwards.com/?page_id=23176
 Radiologic anatomy of the brain:
❖Lobar anatomy and
boundaries:

• Two identical T1 WIs images

are shown in the sagittal plane.

• The right image has been

annotated to show the location
location of the parieto-occipital
sulcus (red line) and the https://www.stepwards.com/?page_id=23176
calcarine sulcus (blue line).
CT brain (inferior cut)
showing:
• The most anterior parts of the
frontal lobes occupy the
anterior cranial fossae

• The temporal lobes occupy the

middle cranial fossae

• The cerebellum and brain stem

occupy the posterior fossa

https://www.radiologymasterclass.co.uk/tutorials/ct/ct_brain_anatomy/ct_brain_anatomy_lobes
 Radiologic anatomy of the brain:
Axial and Sagittal non-CE-CT brain images showing the
posterior fossa with annotations
https://www.radiologymasterclass.co.uk/tutorials/ct/ct_brain_anatomy/ct_brain_anatomy_cerebellum
 Radiologic anatomy of the brain:

❖ The ventricular system

• The ventricles are spaces
located deep inside the
brain which contain CSF

Graphic illustration of the

ventricular system
https://www.quora.com/How
-are-the-ventricles-of-the-
brain-connected
Two indentical Axial CT images of the brain at the level of the lateral ventricles with the right handed one
annotated
https://www.radiologymasterclass.co.uk/tutorials/ct/ct_brain_anatomy/ct_brain_anatomy_ventricles
 Two indentical Axial CT images of the brain at the at the level of the third ventricle and foramena of
Monro with the right handed one annotated
https://www.radiologymasterclass.co.uk/tutorials/ct/ct_brain_anatomy/ct_brain_anatomy_ventricles
 Two indentical Axial CT images of the brain at the level of the fourth ventricle and cerebellum
with the right handed one annotated
https://www.radiologymasterclass.co.uk/tutorials/ct/ct_brain_anatomy/ct_brain_anatomy_ventricles
Radiologic anatomy of the brain:

VASCULAR
 Radiologic anatomy of the brain:
❖Vascular:
1- Arterial:

MRA TOF for intracerebral arteries (image courtesy of Osborn)

MR angiography images
of the brain (MRA)
(non contrast- 3D image)

https://twitter.com/radiologyedu
/status/1004697880614113280
 Cerebral Vascular Territories

Antl!rio.- cerl!bral artery (ACA)

• Anterior choroidal artery

• Mtddle cerebral artery (MCA)

• Lateral lenttculoslrlale artenes

• Posrl!rtor cl!rebral artery (PCA)

 Clinical application of the
cerebral vascular territories:

Localize the occluded vessel

https://www.radiologymasterclass.co.uk/gallery/ct_brain
/ct_brain_stacks/occipital_infarct_ct_brain
A B
 MR venography of the brain ( MRV )

MRV of the brain 3D reconstructed images in different projections

https://twitter.com/radiologyedu/status/1052586730728116225
Gross abnormalities in
brain imaging scans
Types of Intracranial acute hemorrhage
(hyperdense )
 Acute Intraparenchymal hemorrhage
• Acute accumulation of blood
with in the parenchyma of the
brain

• Hypertension is the m ost

common cause of in tracerebral
hemorrhages. (hypertensive
hemorrhages )

• Appears as hyperdense
hematoma within brain
parenchyma (acute stage )
mainly basal ganglia region
Subdural vs epidural hemorrhage
 Subdural vs epidural hemorrhage

• Biconvex (lemon) • Crescentic

shaped (banana) shaped
hyperdense acute hyperdense acute
epidural Subdural
hemorrhage hemorrhage
 Subarachnoid hemorrhage
• Presence of blood within
the subarachnoid space.

• Mostly due to rupture of

arterial aneurysm

• Hyperdense smearing of
the sulci and cisternae
Brain infarction (hypodense )
 l s c h e :m i c
S t r ·o k e

OR

Intra - c erebral he mo r r ha ge C e r ebral inf ar c tion

( bright white ar ea) ( da r k s ha de d area)
Click to edit Master title style
• Edit Master text styles
• Second level
PART 2
• Third level
• Fourth level
Radiology of the SPINE
• Fifth level
Plain X-ray OF THE SPINE
CERVICAL SPINE (CS) plain x-ray (Standard
views):
• The 3 standard views are: Lateral view - Anterior-Posterior (AP) view -
and Open Mouth view.

Case courtesy of Dr Matt Skalski, Radiopaedia.org, rID: 80305

CS lateral view x ray (normal):

https://www.radiologymasterclass.co.uk/tutorials/musculoskeletal/x-
ray_trauma_spinal/x-ray_thoracolumbar_spine_normal
Checklist for CS lateral view x ray:
1Coverage: All vertebrae must be visible from the
skull base to T1 vertebral level.
2 Alignment: Check the lines:
• The Anterior vertebral line (GREEN) (the line
of the anterior longitudinal ligament)
• The Posterior vertebral line (ORANGE) (the
line of the posterior longitudinal ligament)
• The Spinolaminar line (RED) (the line formed
by the anterior edge of the spinous
processes)
• The posterior spinous line
2Bone: Trace the cortical outline of all the bones https://www.radiologyma
sterclass.co.uk/tutorial
to check for fractures. musculoskeletal/x-
Note: The spinal cord (not visible) lies between the ray_trauma_spinal/x-
posterior and spinolaminar lines ray_thoracolumbar_spine
_normal
Checklist for CS lateral view x ray:
1Coverage: All vertebrae must be visible from the
skull base to T1 vertebral level.
2 Alignment: Check the lines:
• The Anterior vertebral line (GREEN) (the line
of the anterior longitudinal ligament)
• The Posterior vertebral line (ORANGE) (the
line of the posterior longitudinal ligament)
• The Spinolaminar line (RED) (the line formed
by the anterior edge of the spinous
processes)
• The posterior spinous line
2Bone: Trace the cortical outline of all the bones https://www.radiologyma
sterclass.co.uk/tutorial
to check for fractures. musculoskeletal/x-
Note: The spinal cord (not visible) lies between the ray_trauma_spinal/x-
posterior and spinolaminar lines ray_thoracolumbar_spine
_normal
Cervical spine alignment
For assessment of cervical spine
alignment, look for the four
parallel lines
• These lines should follow a
slightly lordotic curve, smooth
and without step-offs.
• Any malalignment should be
considered evidence of bony
or ligamentous injury.

Case courtesy of Assoc Prof Craig Hacking,

Radiopaedia.org, rID: 76069
Checklist for CS lateral view x ray:
1Coverage: All vertebrae must be visible from the
skull base to T1 vertebral level.
2 Alignment: Check the lines:
• The Anterior vertebral line (GREEN) (the line
of the anterior longitudinal ligament)
• The Posterior vertebral line (ORANGE) (the
line of the posterior longitudinal ligament)
• The Spinolaminar line (RED) (the line formed
by the anterior edge of the spinous
processes)
• The posterior spinous line
2Bone: Trace the cortical outline of all the bones https://www.radiologyma
sterclass.co.uk/tutorial
to check for fractures. musculoskeletal/x-
Note: The spinal cord (not visible) lies between the ray_trauma_spinal/x-
posterior and spinolaminar lines ray_thoracolumbar_spine
_normal
Checklist for CS lateral view x ray:
1Coverage: All vertebrae must be visible from the
skull base to T1 vertebral level.
2 Alignment: Check the lines:
• The Anterior vertebral line (GREEN) (the line
of the anterior longitudinal ligament)
• The Posterior vertebral line (ORANGE) (the
line of the posterior longitudinal ligament)
• The Spinolaminar line (RED) (the line formed
by the anterior edge of the spinous
processes)
• The posterior spinous line
2Bone: Trace the cortical outline of all the bones https://www.radiologyma
sterclass.co.uk/tutorial
to check for fractures. musculoskeletal/x-
Note: The spinal cord (not visible) lies between the ray_trauma_spinal/x-
posterior and spinolaminar lines ray_thoracolumbar_spine
_normal
Checklist for CS lateral view x ray (cont.):
5Disc spaces: The intervertebral discs are not
directly visible with X-rays. These spaces are
approximately equal in height.
6Pre-vertebral soft tissue - fractures can
cause widening of the pre-vertebral soft tissue
due to pre-vertebral haematoma.
Normal pre-vertebral soft tissue (asterisks)
Above C4 ≤ 1/3rd vertebral body width
Below C4 ≤ 100% vertebral body width
7 Edge of image - Check other structures.
https://www.radiologymasterclass.co.uk/tutorials/musculoskel
etal/x-ray_trauma_spinal/x-ray_c-spine_normal
Checklist for CS lateral view x ray (cont.):
5Disc spaces: The intervertebral discs are not
directly visible with X-rays. These spaces are
approximately equal in height.
6Pre-vertebral soft tissue - fractures can
cause widening of the pre-vertebral soft tissue
due to pre-vertebral haematoma.
Normal pre-vertebral soft tissue (asterisks)
Above C4 ≤ 1/3rd vertebral body width
Below C4 ≤ 100% vertebral body width
7 Edge of image - Check other structures.
https://www.radiologymasterclass.co.uk/tutorials/musculoskel
etal/x-ray_trauma_spinal/x-ray_c-spine_normal
Checklist for CS lateral view x ray (cont.):
5Disc spaces: The intervertebral discs are not
directly visible with X-rays. These spaces are
approximately equal in height.
6Pre-vertebral soft tissue - fractures can
cause widening of the pre-vertebral soft tissue
due to pre-vertebral haematoma.
Normal pre-vertebral soft tissue (asterisks)
Above C4 ≤ 1/3rd vertebral body width
Below C4 ≤ 100% vertebral body width
7 Edge of image - Check other structures.
https://www.radiologymasterclass.co.uk/tutorials/musculoskel
etal/x-ray_trauma_spinal/x-ray_c-spine_normal
Clinical application of
the vertebral lines'
alignment
CS plain x-ray lateral view
showing:
• Fractures at both C5 and
C7 vertebra.
• There is loss of alignment
at several levels (orange
and green lines are
disrupted).
https://www.radiologymasterclass.co.uk/gallery/trau
ma/x-ray_spinal_1/fractures_11
Radiologic anatomy of CS in PXR lateral view:
• a) Anterior arch of atlas
• b) Posterior arch of the atlas
• c) Body of C2
• d) Inferior articular process
• e) Superior articular process
• f) Facet joint
• g) Spinous process
• h) Intervertebral disc space

Cervical spine anatomy, original case courtesy

of Dr Andrew Dixon, rID: 32505
CT SCAN OF THE SPINE
CT scan of the spine:
• CT is often used to image fractures, and dislocations.
• As CT is the preferred method for imaging bone structures- CT is
therefore indicated to assess bony pathology, seen on plain
radiography, or when plain radiography is not clear.
• Disadvantages: CT uses ionizing radiation.
Systematic approach for CT spine evaluation
• Apply the same systematic
approach for evaluation of x
ray for evaluation of CT scans
of the spine.

Image: CT for dorsolumbar Spine (sagittal reconstruction)

(bone window)
CT scan of the spine:
• Excellent demonstration of the
bony structures with better
resolution than PXR and
elimination of tissues’
superimposition seen with PXR.

Image: CT for dorsolumbar Spine (sagittal

reconstruction) (bone window) showing L3
vertebral fracture, with loss of normal vertebral
alignment and L3 vertebral height.
Ahmad Z. et al., Ann R Coll Surg
Engl. 2014 Oct; 96(7): 502–507.
CT or MRI:
• CT uses x-ray radiation; it is good for visualizing bones and calcified
tissues.
• Magnetic resonance imaging (MRI) is best suited for soft tissues
assessment.
• In trauma cases we use CT scan, but in cases with suspected spinal
cord or soft tissue injuries we use complementary MRI to visualize
this structures.
• CT is also used when MRI may be contraindicated e.g. non-MRI
compatible cardiac pacemakers.
 MRI OF THE SPINE
MRI of the spine (How to
identify T1 and T2 WIs?)
MRI sagittal sequence of the
whole spine:
• T1 WI ( CSF in subarachnoid
space is dark ) (red arrow)
• T2 WI (CSF in subarachnoid
space is bright ) (white arrow)
Advantages of MRI OF THE SPINE over CT scan:
• MRI is the best method to visualize the spinal cord and nerves.
• MRI is very useful for evaluating spinal injuries. It helps diagnose
or rule out acute spinal cord compression:
• MRI is the best method to evaluate disc bulge or herniation.
• MRI is the best method to evaluate ligament injuries.
• MRI is able to detect early signs of infection or tumor.
• MRI is more sensitive than CT scanning for evaluating tumors,
abscesses and other soft tissue masses near the spinal cord.
• MRI is the preferred method for assessing post-operative
complications (bleeding, scarring, infection and recurrence of a
herniated disk).
How to identify T2 and T1 WIs in MRI spine

• MRI of Dorsolumbar spine

• Sagittal plane , T2WI
• Red arrow ➔ CSF ( bright )
White arrow ➔ dorsal cord
• Green arrow ➔ annulus fibrosis
• Yellow arrow ➔ nucleus pulposus

Ain Shams University

How to identify T2 and T1 WIs in MRI spine

• MRI of Dorsolumbar spine

• Sagittal plane , T1WI
• Red arrow ➔ CSF ( bright )
White arrow ➔ dorsal cord
• Green arrow ➔ annulus fibrosis
• Yellow arrow ➔ nucleus pulposus

Ain Shams University

MRI of the Spine:
MRI sagittal sequence of the
whole spine :
• The spinal cord terminates at
the conus medullaris (white
arrow) at approximately the L1
vertebral body level in adults.

Clinical application:
This explains why lumbar punctures
are performed below L2.
Normal spine alignment in sagittal T2 WIs

The same previously mentioned

lines, but in MRI you can see the
ligaments.

Case courtesy of Assoc Prof Frank Gaillard,

Radiopaedia.org, rID: 59206
Sagittal plane foraminal level of LSS
(normal anatomy in T2 WIs):
• This plane demonstrates the boundaries of the
neural foramen (pink outline) : -
• The roof and floor: the pedicles (P)
• Posterior boundary: the superior articular
process of the vertebra below.
• Anterior boundary: the disc and vertebral
body (VB).
• The neural foramina are hyperintense structures
in T1 and T2 WIs due to their high fat content.
• The exiting nerve roots are isointense (red
arrows).
https://www.chirogeek.com/MRI
%20READING/mriReading.html
Axial plane at disc level (normal anatomy in
T2 WIs):
• The disc (white).
• The thecal sac (green).
• The posterior arch (yellow).
• Neural foramen (red).
C B C , I N F L A M M AT O RY A N D
IMMUNE MARKERS
INVESTIGATIVE TEAM
Hematopoiesis
Red blood cells
 • Hemoglobin Level
• RBCs count
• Hematocrit
• MCV

Red blood • MCH

cells • MCHC
• Red cell distribution
width (RDW)
• Reticulocyte count
 H e m a t o c r i t ( Pa c k e d c e l l vo l u m e )
• Measures the volume of packed red blood cells (RBC) relative to whole blood.
 Mean corpuscular volume
(MCV)

• Mean corpuscular volume (MCV) is a laboratory value that measures the average
size of a red blood cell.

• Can be calculated by : (HCT % X 10) divided by (RBC count in million)

• Normal : 80-100 FL

• Decreased in Microcytic anemia

• Increased in macrocytic anemia

 Mean corpuscular hemoglobin (MCH)

• Mean corpuscular volume (MCH) is a laboratory value that measures the average
amount of hemoglobin in individual red blood cell.

• Can be calculated by : (Hb level X 10) divided by (RBC count in million)

• Normal : 27-34 pg

• Decreased in Hypochromic anemia

 Mean corpuscular hemoglobin
concentration (MCHC)

• Mean corpuscular volume (MCHC) is a laboratory value that measures the

concentration of hemoglobin in red blood cells.

• Can be calculated by : (Hb level X 100) divided by (HCT)

• Normal : 30-35 %

• Decreased in Hypochromic anemia

 Red cell distribution width
(RDW)
• RDW is a laboratory value that measures
variation in size of red blood cell

• Normally : 11-14 %

• If increased reflect anisocytosis

• Increased in nutritional deficiency as iron ,

folic acid and B12 deficiency anemia
 Reticulocyte

• Young RBCs that reflects bone marrow activity

• Represent 0.5-2.5% of all RBCs

• Increased reticulocyte count occurs in hemolysis, hemorrhage

• Decreased reticulocyte count occurs in aplastic anemia, bone marrow infiltration by

abnormal cells
Microcytic anemia
 Serum iron Total iron binding FERRTIN Transferrin
capacity TIBC saturation
(TS)

Iron deficiency ꜜ ꜛ ꜜ ꜜ Investigation for

anemia the cause

Thalassemia ꜛ ꜜ ꜛ ꜛ HB electophoresis

Chronic illness ꜜ ꜜ ꜜꜛ ꜜꜛ Investigation for

the cause

Sideroblastic anemia ꜛ ꜜꜛ ꜛ ꜜꜛ BM aspiration

Iron profile in microcytic

anemia
Normocytic anemia
Macrocytic anemia
 White blood cells
• WBCs normal range in CBC 4000-11000 X 3
10 /microliter

• Increased WBCs > 11000 X 3

10 /microliter is called leukocytosis

• Decreased WBCs < 4000 X 3

10 /microliter is called leucopenia
Leucocyte differential
Precent Absolute count
Total WBC 4000-11000
Neutrophil PNL 40-80% 2000-7000
lymphocytes 20-40% 1000-3000
basophil 1% 20-100
eosinophils 1-4% 100-400
monocytes 2-8% 200-800
Blast 0 0

Wbcs differential
 Neutrophils
• Neutrophilia occurs in : • Neutropenia occurs in :
➢Bacterial infection ➢Viral infection
➢Inflammation ➢Aplastic anemia
➢Stress ➢Drug induced
➢Steroid therapy
➢Hemolysis, hemorrhage

• Agranulocytosis: absolute neutrophil count < 500, may be asymptomatic or may

cause fatal infections
 Lymphocyte
• Lymphocytosis occurs in : • Lymphopenia occurs in :
➢Viral infections ➢Autoimmune diseases
➢Bacterial infections (brucella, ➢Steroid therapy
typhoid) ➢Aplastic anemia
➢Acute lymphoblastic leukemia ➢Hodgkin lymphoma
➢Chronic lymphocytic leukemia ➢HIV
 Monocyte
• Monocytosis occurs in : • Monocytopenia occurs in :
➢Bacterial infections (TB, brucella) ➢Hairy cell leukemia
➢Leukemia, lymphoma ➢Steroid therapy
➢Autoimmune Disease ➢Aplastic anemia
 Eosinophils

• Eosinophilia occurs in :
➢Allergy
➢Parasitic infections
➢Hodgkin's lymphoma
➢Addison disease
 Blast cells
• Immature WBCs

• 0 % in peripheral blood

• 0-5 % in bone marrow

• Appearance of blast cells in peripheral blood or increased percentage in bone

marrow may indicates acute leukemia
 Platelets

Normal platelet count 150-400 X 103 / microliter

• Increased platelets • Decreased platelets

(thrombocytosis) occurs in : (thrombocytopenia) occurs in :
➢Iron deficiency anemia ➢Hypersplenism
➢Hemorrhage, hemolysis ➢Aplastic anemia
➢Infection, Inflammation ➢Bone marrow suppression (viral,
drugs, radiation, leukemia, lymphoma)
➢Splenectomy ➢Immune mediated (ITP, TTP)
 BLEEDING DISORDERS
Causes of bleeding disorders
• Vascular : congenital and acquired as scurvy, steroid----increase BT
• Platelet -------increase BT
✓Thrombasthenia defect in platelet function
✓Thrombocytopenia decrease in platelet Number
✓Decrease production as aplastic anemia , irradiation increased destruction
hypersplenism ITP, TTP
• Clotting factors----PT,PTT
✓Congenital : hemophilia-von Willebrand
✓Acquired: liver disease, malabsorption, DIC
BLEEDING DISORDERS
 L A B O R AT O RY F I N D I N G I N B L E E D I N G
DISORDER
PTT PT BT Plat. count
Hemophilia Prolonged Normal Normal Normal
Von Willebrand Prolonged Normal Prolonged Normal
Thrombocytopenia Normal Normal Prolonged Low

Thrombasthenia Normal Normal Prolonged Normal

Vit. K def Prolonged Prolonged Normal Normal

DIC Prolonged Prolonged Prolonged Low
 I N F L A M M AT O RY M A R K E R S
ESR
• ESR measures the rate at which red blood cells in anticoagulated whole blood descend in
a standardized tube over a period of one hour .
• It is non specific indicator of presence of a disease, prognostic not diagnostic, must be
used along with other clinic findings
• Normal ranges: men 3 mm/h, women 7 mm/h
• ESR values >100 mm/hour, there is a 90% probability that an underlying cause would
be found upon investigation
 I N F L A M M AT O RY M A R K E R S
ESR
ESR is increased in ESR is decreased in

❑ Inflammation ❑ Polycythemia
❑ Pregnancy ❑ Hyper viscosity
❑ Anemia ❑ Sickle cell anemia
❑ Autoimmune disorders ❑ Leukemia
❑ Infections ❑ Low plasma protein (due to liver or kidney
❑ Some kidney diseases disease)
❑ Some cancers (such as lymphoma ❑ Congestive heart failure
and multiple myeloma
 I N F L A M M AT O RY M A R K E R S
C R P = C R E AC T I V E P ROT E I N
• CRP is an acute phase reactant produced in the liver in response to inflammation
or infection (mostly bacterial).
• CRP is a more sensitive and accurate reflection of the acute phase response than
the ESR.
• CRP returns to normal more quickly than ESR in response to therapy.
IMMUNOLOGICAL MARKERS
 Investigative lecture
(kidney/Electrolytes/ABG)
Internal medicine department-MTI
Kidney investigations

• Laboratory (eGFR ,serum Creatinine , Urea, urine analysis,

electrolytes, arterial blood gases (ABG), CBC)
• Radiology (KUB, U/S, CTUT,IVP, RENAL SCAN )
• Renal biopsy
1.GFR
GFR (Glomerular filtration rate ) •
• Clearance is used as an indicator of glomerular filtration rate, which
provides a useful index for the number of functioning glomeruli
• C = UxV/P ml / min.
•C =Clearance
•U =Concentration of substance in urine
•P =Concentration of substance in plasma
• V = Urine flow rate in ml/min
2-Creatinine clearance
1- Cc = urine cr x urine vol x 1.73/ scr X480xBSA
• CrCl Cockroft-Gault (140- age) x( weight) x 0,85/72x Serum creatinine
• Normal value: (90-140 ml/min)
2 -Urea clearance.
3 -Inulin clearance.
4 -Paraminohipuric acid clearance.
• PAHA is completely cleared from the blood by tubules and its clearance is a
useful mean of determining renal plasma flow .
• Normal value: 650 ml / min.
3.Serum Creatinine

• Creatine is synthesized mainly in the liver from arginine , glycine and

methionine , creatine loses water to from creatinine which is released
into plasma at a relatively constant rate that proportional to the
individual’s muscle mass.
• Normal value
• Male : 0.9 – 1.5 mg/dL
• Female: 0.7 – 1.3 mg/dL
Increased CR DECRESAED CR

Acute renal failure Pregnancy

Chronic renal failure Decrease muscle bulk
Acute glomerulonephritis Steroid
Chronic glomerulonephritis Starvation
Decrease renal perfusion Wasting diseases
Post renal (obstructive
uropathy )
• An isolated serum creatinine (SCr) test may be deceiving, since it may
be low (0.5 mg/dL) just because of decreased muscle mass or high
(1.6 mg/dL) due to large muscle bulk.
• Therefore, serum creatinine values should always be compared to a
given patient’s baseline. A doubling of the SCr means a 50% reduction
in their GFR.
4-Urea and BUN

• Urea is the major non protein nitrogenous waste products of protein

catabolism. It is twice of the BUN. It is less useful than cr for
determining renal function
• Normal value of urea 20 – 40 mg/dL. BUN 10-20
• BUN cr ratio normally 10-20 : 1 if > 20 denote prerenal failure
INCREASED UREA DECREAED UREA

Pre renal (heart failure, Hge, shock) Malnutrition

Renal : acute and chronic RF, acute Liver disease
and chronic GN, tubular necrosis Severe vomiting and diarrhea
Post renal obstructive uropathy SIADH
5-Urine analysis:
I-Protein: normally up to 150 mg/day.
• Types of proteinuria:
• Intermittent
• Functional as after exercise and febrile condition.
• Orthostatic: after prolonged standing.
• Persistent:
• Prerenal : hemoglobinuria, myoglobulinuria and in multiple myeloma.
• Renal: glomerular, tubular.
• Post renal.
• Microalbumin
• Urine microalbumin measurement is important in the management of patients with
diabetes mellitus, who are at serious risk of developing nephropathy over their
lifetimes. Type 1 has a 30%– 45% risk, and type 2 has a 30% risk.
• Urinary albumin concentrations of 50–200 mg every 24 hours or albumin/creatinine
ratio of 20–30 mg/g are predictive of diabetic nephropathy.
II-Other chemical tests:

• Other chemical tests:

• Glucose Glucosuria most often reflects hyperglycemia, but may also
be caused by defective proximal tubular reabsorption, seen in Fanconi
syndrome.
• Bilirubin/Urobilinogen.
• Ketones
• Nitrite: Gram-negative bacteria reduce nitrate to nitrite, which is a
marker of urinary infection.
• Leukocyte Esterase indicates possible WBCs in urine.
• Hemoglobin/Blood.
III-Cells
• White blood cells (WBC): may be due to pyelonephritis, cystitis, or
intrarenal inflammation (e.g. eosinophils in eosinophilic granulomatosis). If
eosinophils are suspected, they should be stained for with Hansel or Wright
staining. If due to bacterial infection, the WBC should be accompanied by
visible bacteria, but this may not be the case with all microorganisms
(e.g.tuberculosis).
• Bacteriuria: By itself, the isolated finding of bacteria in the urine is of very
limited significance. The most important exception is in pregnant women,
whom you should screen for bacteria and treat. About 30% of pregnant
women with bacteriuria progress to pyelonephritis.

• Renal tubular epithelial cells: appear in the urine during acute tubular
necrosis, as dying tubular cells slough into the urine.
IV-Casts:
• Are collections of precipitated protein in the renal tubule, often capturing
cells which are present there. The most significant casts are RBC casts and
muddy brown granular casts.
• Casts Significance
• Hyaline: Dehydration. These casts develop as an accumulation of the
normal amount of tubular protein; they do not necessarily mean disease.
• Red cell: Glomerulonephritis
• Broad ,waxy: Chronic renal failure
• Granular: Also called “dirty” or “muddy”; are associated with acute tubular
necrosis and represent accumulated epithelial cells
• White cell: Pyelonephritis, interstitial nephritis
• Crystals Uric acid Calcium oxalate Triple phosphate
Important terms :
• Renal insufficiency or azotemia: is AKI, but not to the point of needing dialysis. The term
azotemia literally means the buildup of azole groups or nitrogen in the blood.
• Uremia: describes very severe AKI or CKD in which dialysis or transplantation is needed
to save life. The term ESRD can be used interchangeably.

• Acute kidney injury (AKI), previously called acute renal failure, is a rapid decline in the
glomerular filtration rate (seen as a rise in blood urea nitrogen (BUN) and creatinine)
over several hours to days.
• AKI must be distinguished from chronic kidney disease (CKD), which is the slow decline in
GFR over years (seen in many glomerular diseases such as diabetic nephropathy). The
distinction cannot be made by a single serum creatinine test, but requires serial
determinations. The renal sonogram (U/S) can also help in the distinction.
• AKI is classified as prerenal, postrenal, or intrarenal based on the site and mechanism of
injury
HYPONATREMIA: <135 mEq/l.
divided according to volume status into:
• Hypovolemic hyponatremia: (dehydration, GI loss)
• Euvolemic hyponatremia: (SIADH, thiazides)
• Hypervolemic hyponatremia: (cirrhosis, CHF).
HYPERNATREMIA: >153 meq/l

• Saline infusion, hyperaldostornism

• Non-renal water loss
• Insensible losses: sweating, burns, fever, exercise, or respiratory infections
• GI loss: diarrhea
• Transcellular shift: rhabdomyolysis
• Renal water loss may be caused by renal ADH resistance (nephrogenic DI),
inadequate ADH release (central DI
Lab evaluation will
• show high serum Na,
• low urine Na (<10 mEq/L)
• In diabetes insipidus, the urine osmolality will often be <100mosm/kg, reflecting
the dilute urine
HYPOKALEMIA(<3.5 mEq/L)
• Chronic starvation
• Increased cellular uptake ( cellular shift) as excessive insulin
administration, alkalosis
• Renal loss: diuretics, hyperaldosteronism, cushing
• GIT loss: vomiting, diarrhea, laxative abuse.
• Familial peroidic paralysis
• Clinically: weakness, cardiac arrhythmias, constipation
HYPERKALEMIA (>5.5 mEq/L)
• Increase Intake
• Rhabdomyolysis.
• Massive haemolysis
• K sparing diuretics, ACEI
• Renal failure
• Hypoaldosteronism (Addison)
• Acidosis
• DKA
• Periodic paralysis
• RTA type 4
• Clinically: weakness, arrhythmia, can cause cardiac arrest.
Calcium
• Calcium is the most abundant element in the body. About 99 % of calcium is present in
bone Calcium in blood is present in plasma & about 47% of calcium in plasma is ionized.
The remainder is largely bound to protein mainly albumin.
• Serum calcium levels should be corrected when albumin levels are reduced. Serum
ionized calcium is the physiologically active fraction & is controlled within narrow limits
by Parathyroid hormone (PTH), Dihydroxy vitamin D AND Calcitonin Total calcium
should be used as a screening test only.
• Total calcium is not an accurate predictor of ionized calcium in critical illness (since
ionized calcium depends on numerous factors including pH, protein levels, sodium level,
and phosphate level). The corrected calcium is a bit better than uncorrected calcium but
remains unreliable. pH abnormalities will affect the affinity of albumin for calcium,
rendering the correction inaccurate.
• Corrected Calcium (mg/dL) = Measured Calcium (mg/dL) + 0.8(4 – Albumin in g/dL)
• Normal range: 8.2- 10.2 mg/dL ionized Ca (4.4-5.2 meq/l) (2.05 – 2.55 mmol/L).
• Panic values: < 7, ≥ 14 mg/dL
HYPERCALCAEMIA :

• Primary Hyperparathyroidism : Tertiary Hyperparathyroidism.

• Malignancy e.g. most solid tumors, metastatic cancer and myeloma.
• Sarcoidosis.
• Vit D intoxication.
• Thyrotoxicosis.
• Drugs : thiazides , lithium.
• Milk-alkali syndrome.
• familial benign hypocalciuric hypercalcaemia (rare; defect in calcium-
sensing receptor).
• HIV can cause both ↑&↓Ca2+ (perhaps from PTH-related bone
remodelling).
HYPERCALCAEMIA diagnosis:
• Clinically: Stones, bones (pain, fracture, ostitis fibrosa cystica, groan s
(vomiting, constipation) pysychic moans, arrythmia, HTN )
Laboratory
• Pointers to malignancy are:↓albumin, ↓Chloride, alkalosis, ↓K+,
↑PO4, ↑ALP.
• ↑PTH indicates hyperparathyroidism.
• Complete blood picture, protein electrophoresis.
• CXR, isotope bone scan.
• 24 h urinary Ca2+ excretion (for familial hypocalciuric
hypercalcaemia).
 HYPOCALCAEMIA:
• Apparent hypocalcaemia may be an artifact of hypoalbuminaemia .
Causes With ↑PO 4:
• Chronic kidney disease.
• Hypoparathyroidism.
• Pseudohypoparathyroidism.
• Acute rhabdomyolysis. Multiple Blood transfusion
• Hypomagnesaemia: : inhibits release of PTH & its actions
• With normal or ↓PO 4:
• Vitamin D deficiency.
• Osteomalacia (↑ALP).
• Acute pancreatitis.
• Malabsorption syndrome
• Over-hydration.
• Respiratory alkalosis (total Ca2+is normal, but ↓ionized Ca2+ due to↑pH).
HYPOCALCAEMIA
• Clinically: Tetany, psychiatric symptoms
• Chvostek
• Trousseau
• Erbs
Phosphorus

• About 85% of all body phosphorus is within bone, (hydroxyapatite), 14% is

intracellular, and 1% extracellular.
• 70% of the extracellular phosphorus is organic (phospholipids) and the remaining
30% is inorganic. Phosphorus is an important component of bone mineral.
• It is essential for structural integrity of cell membranes.
• 15% of the inorganic is protein bound; the remaining is complexed with sodium,
magnesium, or calcium or circulates as free monohydrogen or dihydrogen forms.
• This freely circulating phosphorus is what is measured.Plasma phosphate
normally ranging from 0.80 to 1.15 mmol/L (2.5 and 4.5 mg/dL) accounting for
only 1% of the total body phosphate A satisfactory diet is never deficient in
phosphorus. Vitamin D enhances absorption of calcium & phosphate.
Indication of ABG

• Respiratory failure and monitoring patients on respiratory support.

• Diabetes mellitus.
• Starvation.
• Lactic acidosis.
• Ingestion of NH4CL, ethylene glycol, methanol, and salicylates.
• In cases of diarrhea.
• In cases of renal failure.
Precauctions and procedures:

• Flush heparin through the needle.

• Insert the ABG needle.
• Advance the needle and observe for flashback.
• Allow syringe to self-fill.
• Remove the needle and apply immediate pressure for at least 3
minutes.
• Engage needle safety device.
• Sites for obtaining an ABG sample:
• RADIAL, BRACHIAL, OR FEMORAL ARTERIES.
 NORMAL VALUES

• PaO2 (PO2): Partial pressure of oxygen in arteries (75-100mmHg).

• SO2: Arterial oxygen saturation (95-100%).
• PaCO2: Partial pressure of carbon dioxide (35-45mmHg).
• HCO3: Bicarbonate level (22-26mEq/L).
• pH [Potential of hydrogen]: The measure of the hydrogen ion
concentration in a substance (7.35-7.45).
 PH < 7.35 → metabolic Acidosis

Metabolic :
• Accumulation of acids
• Ingestion or infusion of acids (NH4Cl – HCl).
• Kidney diseases
• Diabetic ketoACIDOSIS
• Alcoholic ketoACIDOSIS
• Lactic ACIDOSIS
• Starvation ketoSIS
• Salicylic acid (Aspirin) poisoning
• Formic acid (Methanol) poisoning
• Loss of bicarbonate.
• Gastrointestinal (Diarrhea)
• Renal (Renal tubular acidosis)
• HCO3- is low
Respiratory PaCO2 is high (TYPE 2 RF)
Accumulation of carbon dioxide
• Respiratory center inhibition: Narcotics
• Restricted respiration
• Kyphoscoliosis
• Sleep apneoa
• Respiratory muscle disorders
• Paralysis (Guillain Barré Syndrome)
• Myopathies/Muscular dystrophies
• Lung diseases
• Asthma
• COPD
pH > 7.45 → Alkalosis

• Metabolic HCO3 IS high

• Loss of acid Gastric (mainly in persistent vomiting).
• Renal (Loss of fluids and sodium [as in excessive diuretics use] →
Hypovolemia
• Hyperaldosteronism → Increased renal acid secretion [loss].
Respiratory PaCO2 is LOW
• During periods of sustained hyperventilation
• Anxiety
• Poisoning with some substances (such as salicylates) that cause
stimulation of the respiratory center in the brainstem.
Hypoxia (PO2 [Low]):
Liver Enzymes & Viral Markers
 Laboratory liver tests
 Markers of synthetic function
1- Serum albumin (3.5-5 gm/dl)
2- Prothrombin time (PT) 11-14 sec and INR
3- Bilirubin
4- ammonia
 Necro inflammatory marker
Liver enzyme (AST & ALT)
 Markers of cholestasis and infiltration
1- Bilirubin
2- GGT
3- Alkaline phosphatse
4- 5NT
Serum Albumin
- Normal value: 3.5-5gm/dL
- It a protein synthesized only in the liver
- It has a long half life

So, serum albumin level is decreased in chronic liver diseases.

It is also decreases in nephrotic syndrome, malabsorption
syndrome, mal nutrition , infections
Prothrombin time (PT):

- Normal value: 10-14 seconds

- Prothrombin is a protein synthesized in the liver
- It has a short half life
- So, PT is prolonged in acute and chronic liver
disease
It also prolonged due anticoagulant, hemophilia,
DIC, vit K deficiency obstructive jaundice
INR (international normalized ratio):

- It is a type of calculation based on PT test

results.
- It is the preferred test of choice for patients
taking vitamin K antagonists.
Liver enzymes (necro inflammatory markers )

- Causes elevated liver enzymes

Acute liver disease ----- marked elevation
Chronic liver disease-----mild elevation
- Non hepatic causes : hemolysis , myopathy, strenuous exercise,
celiac disease
Acute /sever > 10-20 folds chronic /mild <5 folds
-Acute viral hepatitis -Chronic viral hepatitis (B,C,D)
-Autoimmune hepatitis -Autoimmune hepatitis
-Medications and Toxins -Medications and toxins
-Acute budd- Chiari syndrome - Steatosis and steatohepatitis
-Acute bile duct obstruction -Hemochromatosis
-Wilson disease - Wilson disease
-Ischemic Hepatitis - 1-antitrypsin deficiency(ATT)
** Non –hepatic causes :
-celiac disease
-hyperthyroidism
-Medications and toxins in pt with -Alcohol related liver disease
Alcoholic liver disease (AST/ALT>2)
-Liver cirrhosis

**Non hepatic causes ** Non hepatic causes

-Acute rhabdomyolysis -Myopathy
-Strenuous exercise
- Hypothyroidism
Alkaline Phosphatase

A test for cholestasis

Sources:
- bone due to osteoblastic activity
- liver from canalicular and sinusoidal membranes of hepatocytes
- intestine, placenta
Causes of elevated level:
- biliary obstruction leads to marked rise
- Hepatic infiltration, metastasis
- growing children, rickets
Gamma Glutamyl Transferase (ϒGT):

• It is more senstive and specific than alkaline phosphatase So

it is elevated in early biliary obstruction And confirm
hepatic origin of elevated alkaline phosphatase.

• Causes of elevated level:

-Biliary obstruction , hepatic cholestasis, liver infiltration
- Alcohol
- Drugs
Liver function status be estimated by child pough score as follow
Parameter 1 2 3

encphalopathy Non Grade1-2 Grade3-4

ascites non Mild moderate

PT 1-4 above normal 4-6 above normal >6 above normal

INR <1.7 1.8-2.3 >2.3

albumin >3.5 2.8-3.5 <2.8

bilirubin 1-2 2-3 >3

Child A 5-6 well compensated

Child B 7-9 significant functional compromise
Child C 10-15 decompensated
 Jaundice
Bilirubin is a yellowish pigment that is made during the
normal breakdown of red blood cells. Bilirubin passes through
the liver and is eventually excreted out of the body.
Total bilirubin: 0.3-1 mg/dl
Direct bilirubin: 0.1-0.3mg/dl
Indirect bilirubin: 0.2-0.7 mg/dl
Unconjugated hyperbilirubinemia:

 Indirect bilirubin is more than 85% of total bilirubin.

 Most common cause: hemolytic anemia, Gilbert, criggler najar

Conjugated hyprebilirubinemia:

 Direct bilirubin is more than 85% of total bilirubin.

 Most common cause: obstructive or hepatocellular jaundice dubin
jhonson
Viral markers

Viral Markers
HAV HBV HCV
HAV: IgM: HBsAg :Present in acute or chronic HCV ab : denote
denote acute infection , Detectable 1 to 2
hepatitis remain
acute or chronic
weeks after infection
positive for 3-6 infection
months after the HBeAg :Appears shortly after
primary HBsAg ,Indicates viral HCV PCR: used to
infection Replication and Infectivity detect viral RNA
HBsAB(Anti-HBS) :Present after used to prove
Anti-HAV IgG vaccination or clearance of
denote past HBsAg(Usually 1 to 3 months) infection
infection appears
after IgM and
Indicates immunity to HBV
persists for many Hb core Antibody (IgM anti-Hbc
years or IgG anti-HBc)
Only Serological marker of HBV
during "Window Period
Alpha Fetoprotein

 AFP is a glycoprotein
 Is marker of hepatocellular carcinoma, and cancer testis
 AFP > 1000 ng/ml indicates HCC
 AFP is elevated in only two-third of HCC patients. Currently, AFP
is not just a biomarker, but also a risk factor of tumor recurrence for
liver resection and liver transplantation.

Non malignant causes of elevated AFP

 Pregnancy
 Hepatitis , cirrhosis
 Lab. Studies of Ascitis
 A diagnostic aspiration of 10-20mL of fluid should be
obtained for chemistry, bacteriology, cytology
 Cell count: a white blood cell count is the most
important
 a neutrophil count above 250 cells/mm3 is indicative of
and underlying spontaneous bacterial peritonitis
 an elevated lymphocyte count arouses suspicion of
tuberculosis or peritoneal carcinomatosis
 Gram stain and culture:
for bacteria and acid fast bacilli
 Serum-Ascites Albumin Gradient
Best single test for classifying ascites into portal hypertensive and non-portal
hypertensive causes
 Calculated by:
Subtracting the ascitic fluid albumin from the serum albumin

SAAG >1.1= Portal HTN SAAG <1.1= Non-Portal hypertensive

Liver Disease Peritoneal carcinomatosis

Hepatic Congestion Peritoneal Infection
CHF (TB, Fungal, CMV)
Tricuspid Insufficiency 3. Nephrotic syndrome
Massive Hepatic Metastasis 4. Pancreatic ascites
Transudate Exudate
Clear clorless Yellow, turbid, bloody
TP < 3 g/dL TP > 3 g/dL
LDH<200 >200
Sp G <1015 >1015
Cell count <1000 >1000
• Liver disease (commonest). • GIT malignancy
• Congestive heart failure. • Intestinal TB
• Nephrotic syndrome. • Bacterial peritonitis
• Malnutrition (Malabsorption • Chronic pancreatitis
syndrome).
 Amylase and lipase
- Amylase and lipase are digestive enzymes normally released
from the acinar cells of the exocrine pancreas into the
duodenum.
- Following injury to the pancreas,
Lipase is more sensitive and specific than amylase in
diagnosing acute pancreatitis .
Therefore, normal lipase level in the setting of acute
abdominal pain is often used to rule out a diagnosis of acute
pancreatitis,
lipase 3 times of normal is diagnostic for acute pancreatitis
DM, lipid &hormonal tests
 By the end of this lecture, learner will
be able to:
• Identify indications for thyroid function test.
• Interpret biochemical investigation in thyroid
disorders
• List different abnormalities of parathyroid gland.
• Correlate between parathyroid disorders and
calcium metabolism
• Know how to diagnose a case of diabetes
• Investigate Cushing and know the etiology
 Case 1

19 year old female patient

presented to the clinic
complaining of awareness of
heart beats ,up to the degree
that she is unable to sleep and
is always nervous.
On further questioning , she told you
that in spite of increased appetite she
is losing weight , she also told you that
she has to run to the toilet after any
meal but there is no obvious diarrhea.

What is the D.D of this patient?

 Palpitation
+
Anxiety and Insomnia
+
weight loss
+
increased appetite
+
hyper-defecation
 On examination
• Patient was alert but irritable
• BMI: 18.3kg/m 2

• Starring look with infrequent blinking

Her pulse was 110bpm,

blood pressure 140/70
temperature 37.5c

• She had ? (Fine /coarse) tremors and her hands were hot and
sweaty

• Her neck showed a swelling

 In light of your provisional diagnosis…
• How would you investigate this patient?

TFT:

TSH
Free T3
Free T4

Imaging studies: Neck US, radioisotope scan

 Thyroid Scan

• In case of hyperthyroidism, a radioactive iodide

uptake test is typically performed in order to
determine the underlying cause of the condition.
This test will determine how much of the iodide is
absorbed by thyroid.
• If the test shows that you thyroid gland is
absorbing excessive quantities of the iodide, then
the iodide uptake test will indicate where most of
the iodide is collecting in your thyroid gland. This
will show what part of your gland is producing
the excess amounts of thyroid hormone.
 Thyroid Antibodies

✓Thyroglobulin
✓Thyroid peroxidase – TPO
✓Thyroid stimulating hormone receptor
antibodies – TRAbs
 Investigation was ordered
• TSH: suppressed
• FT3:
• FT4:

• TRAbs : +ve

• US: diffuse goiter with hypervascularity

 Thyroid scan
RAI uptake Interpretation

Diffuse Low uptake thyroiditis

Diffuse increased uptake Graves disease

Nodule of increase uptake Toxic nodular goitr

Diagnosis

Graves Disease
 The patient received
Antithyroid medication but unfortunately there was
no improvement so she was advised to receive
radioactive iodine,

Few months later, the patient complained of

constipation and lack of concentration.

What do you expect????

thyroid function test
 Case 2
• A 40-year-old man goes to his general
practitioner (GP) because he has become
increasingly overweight. He has gained 8 kg in
weight over the past 6 months. He has noticed
that he is constantly hungry. He has found that he
is bruising easily. He finds it difficult to get up
from his chair or to climb stairs.

• He feels depressed and finds himself waking

early in the mornings. He has had no previous
physical or psychiatric illnesses. He is a teacher,
lives with his wife and 2 children. No special
habits of medical importance.
 truncal obesity
+
easy bruising
+
difficulty in standing from sitting position
+
depression
By Examination
• pulse is 76/min, regular

• blood pressure 168/104 mmHg.

• Overweight particularly in the abdominal region.

• There are purple stretch marks on his abdomen and

thighs. His skin is thin, and there are spontaneous
bruises.

• There is peripheral oedema.

• neurological examination is otherwise normal,

apart from some weakness in shoulder abduction
and hip flexion

• Otherwise, examination of his heart, respiratory

and abdominal systems is normal.
Provisional Diagnosis

Cushing $
 Causes of Cushing

Cushing

ACTH Non ACTH

dependent dependent

Ectopic
Pituitary Adrenal Drug induced
(Para malignant)
Diagnostic approach of Cushing
24h urinary cortisol (high)

Overnight dexamethasone suppression test

Cortisol (high)

Low dose dexamethasone suppression test

(LDDST)

No suppression

Cushing
 Cushing

ACTH

low High

Adrenal Cause High Dose Dexamethasone

Suppression Test (H.D.D.S.T)
( CT ABDOMEN)

Suppression No suppression

Pituitary cause Para malignant

(MRI pituitary) CT “neck, chest
pelvi abdomen”
Case 4
 Case 5
• A 45 year old female patient presented to the
clinic with circum-oral numbness, when you
started to examine her blood pressure , there
was a painful carpal spasm on her hand.
In light of your knowledge, you suspected that
this patient may have HYPOCALCEMIA