Thromboemboly of pulmonary artery

Thromboemboly of pulmonary artery (TEPA) takes place as a result of pulmonary truncus some branches obturation by a blood clot. More frequent all happens as the result of complication in the after-operational period, or the patients in tied down to the bed, when thrombophlebitis of inferior extremities develops. Roentgenological appears darkening with unclear contours, pleura exudate is possible. Obturation of large branches of pulmonary truncus results in an acute pulmonary heart, when the right departments of the heart are increased and superior vena cava and arc of pulmonary truncus broadens. Perfusional scintigraphy at TEPA finds out in lungs an area with reduced perfusion. Angiopulmonography specifies oclusion of what pulmonary artery took a place.

Fig.17.13 Coloured spiral CT thromboemboly of left pulmonary artery branch

The diaphragm diseases radio signs

The basic method of examination of diaphragm is roentgenological. By rentgenoscopy determine position, character of motion of diaphragm cupulas, size of their excursion (in a norm - on 1-2sm during the quiet respiratory and on 4-5sm - during deep). Patients are inspected in horizontal and vertical positions, often utillize contrasting of stomach and intestine. Sciagraphy allows more detailed to learn and to document the found out pathology. The basic diseases of diaphragm are relaxation (loss of tone) and hernia.

Diaphragm relaxation is distinguished born as the result of undeveloped diaphragm muscle and purchased as the result of damage or compression of diafragmal nerve. There is pride of place of diaphragm cupulas at relaxation, those respiratory motions are limited. Total relaxation of the left cupula of diaphragm happens usually, although can be and lobar weakening of diaphragm, more often business. Diaphragm integrity is saved here, that allows to distinguishing relaxation from hernia. By CT, MRI can more precisely define the high standing of diaphragm and its thinning.

Penetration of organs of abdominal region to the breast through defects in a diaphragm is the diaphragm hernia. After etiology distinguish untraumatic and traumatic diaphragm hernia. Reasons of formation of untraumatic hernia can be born defects, weak points, largenesses of natural diaphragmal foramens.

A born hernia of diaphragm happens rarely. In a thoracic cavity thin and thick bowels get more often. Clinical displays are characterized by age of patient, by an amount and by volume of moved organs: in new-born there is cyanosys, shortness of breath, vomit; for the children of senior age characteristic symptoms can be absent. Roentgenological the uneven darkening appears above a diaphragm with the separate areas of brithening, in which sometimes there is liquid, which forms horizontal lefvels which are displaced in the case of sick child position change.

The weak points of diaphragm are its dual triangles. Clinical diagnostic of these hernias is inexpressive. Roentgenological they appear in a kind loy of the district shade of different sizes with heterogeneous structure, clear contours in the area of diafragmal-mediastinal recess in the anterior view. In lateral projection hernia of brest-costal triangle of diaphragm (Lorreya) is localized in the area of the anterior rib-mediastinal recess, and hernia of lumbar-costal recess (Bogdaleko) to the area of back recess, their maintenance is part of colon with a stuffing-box, stomach, loops of thin bowel. Heterogenisy of structure is coused by the different closeness of tissues, placed in a hernia sack, gas blisters. Hernia of esophagus foramen of diaphragm shows by itself a hit through extended esophagus foramen in back mediastinum of cardial department of stomach. Such hernia can be fixed and unfixed (sliding). Among sliding hernia axial distinguish and paraesophageal. At presence of axilar hernia cardial part of stomach periodically or constantly displaced in a thoracic cavity, a esophagus fully is in a thoracic cavity. At paraesophageal hernia the vault of stomach penetrates in a thoracic cavity, sometimes a stuffing-box, cardial part of stomach and abdominal part of esophagus, remain under a diaphragm. Hernia is easily managed, but can be hurt. Patients grumble about heartburn, belch, and pain after a breastbone.

Roentgenological on a background shade hearts find out brightening of gas blister of stomach, sometimes with the horizontal level of liquid. For the exposure of hernia esophageal foramen of diaphragm applies contrasting of esophagus and stomach barium mixture, it is asked to accept a patient horizontal position and to strain the muscles of abdominal press.

RADIODIAGNOSTIC OF THE DISEASES OF MEDIASTINAL ORGANS

After the International anatomic nomenclature mediastinum is divided on 4 departments: superior, anterior, middle and posterior. Superior mediastinum of situated higher horizontal line, conducted between the places of connection of handle of sternumwith its body to intervertebral disk between 4th and 5th thoracic vertebrae. Middle mediastinum contains the heart with perycardium and root of lungs. Anterior mediastinum is before of the heart and roots of lungs, and back mediastinum - behind.

On a sciagram in a anterior view the organs of mediastinum appear as intensive middle shade in formation of which a basic role plays a heart and large vessels.

On a sciagram in a lateral projection in superior mediastinum it is possible to trace the vertical bar of brightening of trachea in a width 1,5-2,0 sm, shade of arc of aorta, in children - shade of thymus; on a background brightening of retrosternal spatium it is possible to see the lung pattern of superior lobes of lungs. In anterior mediastinum on a background retrosternal spatium noticeable lung pattern of uvular segments, segments of middle lobe of lungs. In middle mediastinum is well noticeable shade of heart, and under bifurcation of trachea - scolded lungs. In back mediastinum on a background retrocardial spatium the lung pattern of inferior lobes of lungs is traced, and for old people often noticeable sclerotic descending part of aorta. Lymphatic nodes of mediastinum in a norm do not give shade and the noticeable become on a sciagram only in the case of increase or calcification.

Often the different diseases of organs of mediastinum have similar clinical displays: pain or feeling of compression after a breastbone, shortness of breath, cough, tachycardia, dysphagia, neuralgia, and compression syndrome. Sometimes they give no clinical symptoms, but appear during prophylactic roentgenological examinationes.

Localization of pathological education in mediastinum on a sciagram in a anterior view characterize the presence of pathological shade with a prevailing vertical size which is formed from above and from below by middle shade obtuse angles. Volume formation moves mediastinal pleura outside, almost immobile during respiratory.

By linear tomography, bronchography, pnevmomediastinography (introduction of gas into mediastinum), angiography it is possible to find out position of patological education, his structure, displacement and compression of trachea. High settling ability, possibility of establishment of mutual relations, in particular germination in contiguous structure, determination of different tissues after a densitometrical closeness at CT and intensity of signal at MRI does these methods of radio examination of high-sensity and high-specific in diagnostics of diseases of mediastinal organs.

The diseases of mediastinal organs are tumours, cysts and inflammations of connecting tissue (mediastinitis).

Malignant tumours, which strike interthoracal lymphatic nodes, or lymphoma (lymphosarcoma, lymphogranulematosis, lympholeycosis and metastases in these lymphatic nodes have similar clinical and roentgenological displays. Patients grumble about a general fatigue, pain in the area of thorax, cough, increase of body temperature, decline of body mass. Roentgenological the bilateral appears in the anterior view, rarer one-sided, expansion of middle shade, external contour of what gor-bistiy and sufficiently clear; scolded lungs are extended due to the increase of bronchopulmonary lymphatic nodes. In a lateral projection is noticeable shade of wrong form mainly in superior mediastinum. On linear, computer and magnetically resonance tomogramas increasing of mediastinal lymphatic nodes appears expressly, often accompanied displacement of trachea and main bronches. For malignant tumours characteristic hasty growth and germination is in surrounding organs (trachea, esophagus, wall of aorta, pericardium). Lymphosarcoma and lympholeycosis have a high sensitiveness to radio therapy, lymphogranulematous - low, and bening tumours are quite irresponsive on a ray. A differential diagnosis is conducted on the basis of analysis of blood and information of biopsy of megascopic peripheral or interthoracal lymphatic nodes by transthoracal or to the transbronchial biopsy. For differential diagnostic with tuberculosis of intrathoracal lymphatic nodes take into account information of anamnesis, presence of tubercular foci in lungs, tests with tuberculin.

Bening tumours and cysts, as a rule, are disposed; their sizes are increased slowly by years. They displace nearby organs (trachea, esophagus), clinical displays absent long time, on sciagrams in a anterior view pathological shade is one-sided, has clear contours.

Determination of localization of pathological shade is on the sciagram of organs of thorax in a lateral projection, or on CT or MRI, often is a deciding factor for the exposure of nature of disease and rising of diagnosis.

Retrosternal goiter takes place in the anterior department of superior mediastinum. He develops from the mews of thyreoid gland, which goes during embrional development. On a sciagram in a lateral projection the contours of shade are clear, from above it is wider and gradually passes to the shade of neck`s soft tissues from below narrower and can arrive at the arc of aorta. Often there is a compression and displacement of trachea, and also displacement of the shade during swallowing or cough.

Thymoma is a tumour of thymus which will strike mainly young men. The development of tumours and cysts of thymus often show up the signs of making progress muscular sickliness (myastenia), by the symptoms of squeezing of trachea with difficulty of respiratory, violation of circulation of blood, disphagia. Thymoma has an oval form, located in anterior and superior mediastinum. Of bening tumours make swingeing majority of thymus tumours (80%), but often they can becom malignant. For differential diagnostics of bening and malignant tumours it is necessary to take into account their rates of growth, connection with adjoining organs. Shade of bening tumour is homogeneous, contours levels are clear. The rapid increase of the tumour sizes, appearance of wave contours, loss of their clearness, testify about the presence of malignant process. There is a displacement of mediastinal organs at bening growth, and at malignant is a germination of tumour in them.

Tracheobronchogenic and esophagoenterogenic cysts are the defects of development, which arise up as a result of removing a layer by the layer of embryo tissues which aire ways and esophagus develop from.

Tracheobronchogenic cyst is usually placed from a trachea or under bifurcation of trachea. It has a round or oval form, homogeneous structure, clear external contour, can arrive at largenesses (to 10sm). The contrasted esophagus at the level of cyst is archwise declined back, some compresed. Sometimes in a capsule cysts look after dissemination of salts of calcium. Development of tracheobronchogenic cyst can be complicated inflammations, suppurations, it burst in a bronchus or trachea. In such case in mediastinal cavity appears the horizontal level of liquid.

Esophagoenterogenic cyst is more often and is localized in the back mediastinum, related to the esophagus which can be archwise declined and compresed. The contour of esophagus is clear; relief of mucus shell is not changed. Dermoid cyst and teratoma is also related to the defects of the development of a man. Dermoid cyst is built from a thick connecting tissue shell, covered an epithelium, and teratoma is solid education which has cysic areas. They are localized more often in anterior mediastinum, on one side of thoracic cavity. Roentgenologicaly is shown up single shade of the rounded form with clear external contours; an internal contour is not traced. A structure of shade can be homogeneous, that characteristically for a dermoid cyst, or heterogeneous with caslcification, that characteristically for teratoma. The table of contents of dermoid cysts and (mucous liquid, fat, hairs, teeth, calcification) sometimes can break through in a bronchus and appear in sputum.

Neurinoma (neurilema) is bening tumours which develop from nervous tissue, more often from spinal nodes. Neurinoma takes place near a spine, grow slowly, without simptonms, can arrive at largenesses, and then dull aching pain appears in the back, breasts, that irradiate after motion of intercostal nerves. The roentgenological appears intensive homogeneous shade of the rounded or oval form with clear even contours, which meets with mediastinal shade and vertebral column, not displaced at respiratory. At the considerable sizes of neurinoma often there are expansions of intervertebral foramen, regional defects of back departments of ribs, lateral surfaces and transversal sprouts of vertebra`s bodies.

Lypoma is a bening tumour which takes place from adipous tissue. It is disposed more often in superior and anterior mediastinum. Rentgenologicaly is determined one-sided intensive shade of the rounded form, with a clear external contour which is not displaced during swallowing and respiratory. Little tumours clinically itself are not shown and appear by chance during a roentgenological inspection.

Celomical cyst is a born cyst which arises out of embryo (celomus) body primary cavity more often as thrusting out of cavity core, observed in the diafragmal- mediastinal recess of anterior mediastinum. At roentgenological examination a cyst appears as homogeneous shade of midlle intensity, wrong rounded form with clear contours, that changes a form during respiratory and pulsational motions of heart.

Mediastinitis is inflammation of cellulose of mediastinum, which arises up as a result of traumas of neck and thorax, hit in a trachea and esophagus of extraneous bodies, complications after operative interferences on the esophagus and lungs and others like that. For patients arise up retrosternal pain, which increases during respiratory, swallowing and filling up of chairman. The increase of temperature of body, intoxication is marked. On a sciagram in a anterior al and lateral projection we can see expansion of shade of superior mediastinum with an unclear wave contour and displaced outside mediastinal pleura, sometimes displacement of trachea. In the case of festering defeat and breach of walls of trachea or esophagus it is possible to find out in the cavity of the formed abscess the horizontal level of liquid, and the structure of shade of mediastinum becomes heterogeneous through air which dilated his cellulose. For an exposure the perforations of esophagus execute his contrasting.

In the case of opened pneumothorax air can spread between soft tissues of thorax and there is hypodermic emphysema which clinically appears by palpation, and roentgenological - by appearance at the level of lungs of «feather-like» pattern as a|but| result of muscles stratification by air.

The algorithm of the birthing organs radio examination includes|switches| the following methods: fluorography|, sciagraphy, fluoroscopy|, linear tomography|, computer tomography |, magnetically-resonance imaging|, scintigraphy|, SPECТ|, PAT, radionuclear| scanning, radiometry, and sonography|, which are used in obedience to|in accord with,according to| principle – from more simple to|by| more difficult|complex|: