ROTATION ORIENTATION

Download presentation
1 - 20

laxreffa's Recent Documents

Nasir, N. et al.: Distribusi penyakit layu fusarium dan
Nasir, N. et al.: Distribusi penyakit layu fusarium dan

215 layu bakteri ralstonia pada lokasi ... J. Hort. 15(3):215-222, 2005 Intensitas serangan penyakit layu pisang di Provinsi Sumatera Barat paling tinggi dibanding - kan dengan provinsi-provinsi lai

published 0K
The CFIP Series Full Outdoor Unit Technical Description and Configurat
The CFIP Series Full Outdoor Unit Technical Description and Configurat

 SAF Tehnika2011          OutdoorUnits...................................................................................................................FeatureMechanicalInterfaces/Manage

published 0K
) to continually recompose a particular framework or model that identi
) to continually recompose a particular framework or model that identi

In his an depends on leaving and returning to the kumbengo repertoire and performance practice. In general, styles of presentation that emphasize instrumental playing (foli) prevail in clubs and conce

published 0K
ROTATION ORIENTATION
ROTATION ORIENTATION

GI/GU 2018 Welcome to Abdominal Radiology. The fluoroscopy service is an integral component of the Abdominal Imaging service. On this service, residents will learn to interpret plain radiographs of

published 0K
	\n	\r\r
 \n \r  \r  

  !1 1% $112      0�   8 :   ?        88  : 

published 1K
Aus: LSF_Vorlesungsverzeic
Aus: LSF_Vorlesungsverzeic

hnis DuE_WS 2013/14_Wirtschaftswiss. _Stand: 07.08.2013 1 Lehramt (Staatsexamen) Das nachfolgende Lehrangebot enth

published 0K
.Thus,thepoint(
.Thus,thepoint(

E Thevalueof!0and!1minimizingQcanbederivedbydi!erentiatingQwithrespectto (Xi"

published 0K
[Cite as State v. Bari, 2008-Ohio-3663.]
[Cite as State v. Bari, 2008-Ohio-3663.]

EIGHTH APPELLATE DISTRICT COUNTY OF CUYAHOGAJOURNAL ENTRY AND OPINION No. 90370JUDGMENT: AFFIRMED July 24, 2008 [Cite as State v. Bari, 2008-Ohio-3663.]N.B. This entry is an announcement of the c

published 0K
Download Section

Download - The PPT/PDF document "" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.






Document on Subject : "ROTATION ORIENTATION"— Transcript:

1 GI/GU ROTATION ORIENTATION 2018
GI/GU ROTATION ORIENTATION 2018 Welcome to Abdominal Radiology. The fluoroscopy service is an integral component of the Abdominal Imaging service. On this service, residents will learn to interpret plain radiographs of the abdomen and pelvis and to perfo rm and interpret fluoroscopic studies of the gastrointestinal and genitourinary systems. Here are a few helpful hints to help you make the most of the rotation. Please see the "goals and objectives" attachments (separate) for specific goals for each ye ar's rotations based on the ACGME competencies. Workflow: • The workday begins at 8:00 or immediately following morning conference. • Readouts occur throughout the morning and afternoon. • The resident should preview and dictate abdominal plain films before read out and gather clinical information regarding the patient’s history, indications prior to readout , and prior imaging . Once they have been reviewed with the attending, the resident should promptly make changes to report if necessary. • All abdominal STAT and ED plain films need to be looked at and dictated ASAP, and then immediately reviewed by an attending. • The GI/GU fluoroscopy list should be reviewed in the am. Clinical information regarding the patient’s history , pertinent laboratory tests and previous imaging studies , and indications for the study should be reviewed prior to study to be certain that the proper test has been ordered, that the patient’s condition is such that the examination is safe and that any necessary preparation for the test has been completed before starting the examination. If it is at all unclear what the clinical question or reason for exam is, then the ordering physician should be contacted to clarify and ensure that the proper examination is performed. • The resident should ans wer questions from the GI technologist, field requests for emergency and add - on studies and should elicit enough clinical history to insure that the correct study is performed for the condition suspected. • All significant findings should be conveyed to the ordering physician in a timely fashion – usually by phone. Our reading room assistants can help locate the physician 984 - 974 - 9345. Be sure to document communication (who, when, and by what method) in the report. Scheduling • The morning is dedicated to GI “fluoro” studies that the res

2 ident is expected to perform with super
ident is expected to perform with supervision. The resident will review and pre - dictate the abdominal plain films in the GI worklists on the PACS, as well as the fluoroscopy studies, and present preliminary impression of the s tudy to the faculty prior to dismissal of the patient. The afternoon is used for additional overflow studies, hysterosalpingograms, and GU studies such as cystograms or nephrostograms, • Three fluoroscopic/ra diographic rooms are available. D aily outpatient s tudies are scheduled. Inpatients will be done the day of or after the physician requests the study. • Diabetic and cardiac patients should be scheduled in the early morning, if possible, to allow medications to be regulated. • Emergency cases will be adde d to the schedule; emergency study usually means that, if the fluoro study demonstrates what the clinicians believe to be present, the patient will receive the appropriate interventional or surgical therapeutic procedure immediately following the radiologi c examination. Exam Preparation and Performance • Please refer to Dr. Warshau er’s Gastrointestinal Radiology P rotocol and Syllabus notebook for routine fluoro examinations – located in the GI/ GU reading room and suggested articles on google drive . • Each exam ination is tailored to the indication of the study to patient’s clinical history, clinical condition or information desired. • C heck EPIC for history, indication for study and prior surgery, etc . • BEs may be performed the day following the superficial endosc opic biopsy that is obtained via a colonoscope, although large amounts of air often preclude an ideal study. • Review all p rior studies, particular ly plain films, GI, CT, US etc . • Before beginning any study, the resident should introduce her/himself to the pa tient. • Rule out the possibility of pregnancy in any female patient of childbearing age. Radiation to the abdomen is particularly likely to be harmful between the second and sixth week post conception but unnecessary radiation should be avoided at any stag e of pregnancy. P ostpone any abdominal radiographic procedures which are elective in nature. • Patients should also be questioned about relevant symptoms, prior abdominal surgery, having been NPO after 9:00 pm. Important concepts to keep in mind prior to pr oceeding with the study

3 include: • The use of rectal ball
include: • The use of rectal balloons should be limited if at all possible; rectal balloons must not be used with known or suspected proctitis or rectal carcinoma. • A barium enema is contraindicated with fulminant colitis, toxic megaco lon or suspected colonic perforation. • If perforation of any portion of the GI tract is suspected, the study should be performed with iodinated water - soluble contrast material. (e.g., Gastrografin, Cystografin) = NO Barium • In suspected aspiration, high osmo lality iodinated water - soluble contrast material (e.g., Gastrografin) is contraindicated; when these contrast agents come into contact with the lung they cause a severe pneumonitis. • Consult the attending radiologist regarding use of Omnipaque (a nonionic, isotonic iodinated agent) in complex situations. • “Good fluoroscopy is 95% based on anatomy and gravity.” (How must you position the patient in order to get the contrast material &/or air where you need it?) PROCEDURES AND TECHNIQUES Preliminary Supine Abd ominal Film Prior to GI Contrast Examination A preliminary (“scout”) film of the abdomen prior to a fluoroscopic exam is not routinely performed because of proven low - yield, radiation exposure and cost. However, it should be obtained in any patient who has had previous surgery or intervention (e.g. biopsy or balloon dilation) because surgical staple lines and other “artifacts” may simulate pathology, such as a leak of contrast medium. Plain Abdominal Films Techniques For adults, the lower edge of the film is centered on the superior margin of the symphysis pubis. For a large patient, two (14 x 17) films cross - wise. Lower edge of one on symphysis, lower edge of the other on iliac crest. With optimum exposure both lateral properitoneal fat lines should be vi sible on all films. Single Abdominal Film or KUB (kidneys, ureter and bladder) Indications • Preliminary for many studies. • Search for masses; calcifications, particularly gallbladder, appendix or kidney; position of tubes and catheters Three - Way Abdominal Study • Necessary for evaluation for bowel perforation and obstruction. • Supine . • Upright . • Left lateral decubitus, patient remains in this position 10 minutes prior to filming (ideally) • For the upright and decubitus films, the X - ray beam must be horizontal. An upright PA

4 chest is often obtained unless one ha
chest is often obtained unless one has been done within a few hours. This enables the examiner to exclude lung or diaphragmatic disease as the cause of the abdominal symptoms. Lower lobe abnormalities are often better seen on an abdominal film than on chest x - rays. It will also confirm the presence of free intraperitoneal gas. Approach to Abdominal Plain Films D evelop a systematic pattern for reading abdominal radiographs. Do not focus immediately on a perceived abnormality but evaluate all in formation available from the film. You might need to go to the EPIC patient record to un derstand the patient’s problems . A lways compare with prior studies if they are available. 1. Supporting Structures Start with “tubes, devices and altered anatomy.” Im portant clues are often available by noting evidence of prior surgery (e.g. skin staples, anastomotic bowel staple lines, “ostomies.”) I dentify the most common types of catheters, drains, surgical devices and foreign bodies, including retained surgical “sp onges” and needles. (See: “Abdominal Incision and Injection Sites,” STATdx) 2. Abdominal Calcifications I dentify renal calculi, gallstones, pancreatic calcifications, vascular calcifications, injection granulomas, and calcified lymph nodes, among others. ( See: Expert DDx: “Abdominal Calcifications” in STATdx) 3. Organomegaly and Masses Hepatomegaly will displace the hepatic flexure down and splenomegaly will displace the splenic flexure down and the stomach medially. The kidneys can be seen, at least partia lly, in most patients because of adjacent perirenal fat. Similarly, the bladder can usually be visualized because of surrounding perivesical fat. Masses may be evident by localized soft tissue density that displaces bowel and other structures. (Read: “RUQ masses”, “LUQ mass,” “ Splenom egaly” in STATdx) 4. Bowel Gas and Fluid Normal stomach = gas + fluid. Normal small bowel (ambulatory patient) =minimal gas. Normal colon = no fluid; formed stool in left side of colon. ** Abnormal gas patterns: Ileus : Increas ed gas and fluid in small bowel (diamete�r 3 cm) and colon �(6 cm) without a transition point. Obstruction : Dilation upstream from a transition point; collapsed bowel downstream Aerophagia : Increased gas within SB and colon, but no significantly dilated s egments. 5. Ab

5 normal Gas Collections ( Read in STATd
normal Gas Collections ( Read in STATdx or articles) 1. Pneumoperitoneum 2. Portal Venous Gas 3. Gas in Bile Ducts or Gallbladder 4. Pneumatosis of SB or Colon 6. Abnormal Fluid Collection CRITICAL RESULTS In the abdomen, critical test result s that MUST be communicated with clinical teams and recorded are as follows: 1. Non iatrogenic pneumoperitoneum 2. Retained foreign body 3. Bowel obstruction with strangulation 4. Misplaced enteric tubes or instruments 5. Complications of procedures or con trast reactions 6. Leaks Potential Contra - Indications • Where GI or GU perforation is suspected use water - soluble contrast first. • Oral barium not given in the presence of colonic obstruction. • Don't give barium prior to ultrasound or CT examination. All re sidents: NOON CONFERENCE: Noon conference : • Noon conference is given by the Abdominal Imaging group on Mondays and the first Wednesday of the block . • Every attempt should be made for the resident to attend noon conference on - time . • IMAGAING PATH Confere nce – The residents are responsible for this conference. A list of surgical pathology reports from recent surgeries will be given to the residents at the beginning of the block. The residents chose 10 cases from this list that have interesting radiologic correlative to present at the end of the block. Go over the cases with the attending assigned to the conference prior to presentation . Recommended Reading and other Educational Resources: There are suggested articles to read on the UNC Radiology google drive (under the abdominal rotation). On the google drive, there are specific folders divided by resident year with a few articles of suggested reading in each folder. Electronic Resources: • Diseases of the Esophagus: Diagnosis with Esophagography. Levin e MS et al. Radiology 2005 . http://dx.doi.org/10.1148/radiol.2372050199 • Double - Contrast Upper Gastrointestinal Radiolography: A Pattern Approach for Diseases of the Stomach. Rubesin SE et al. Rad iology 2008. http://dx.doi.org/10.1148/radiol.2461061245 • Air (CO2) Double - Contrast Barium Enteroclysis. Maglinte DD et al. Radiology 2009. http://dx.doi.org/10.1148/radiol.2523081972 • Double - Contrast Barium Enema Examination Technique. Rubesin SE et al. Radiology 2000. http://dx.doi.org/10.1148/radiology.215.3.r00jn3

6 6642 • P attern Approach for Disea
6642 • P attern Approach for Diseases of Mesenteric Small Bowel on Barium Studies. Levine MS et al . Radiology 2006. http://dx.doi.org/10.1148/radiol.2491071336 • Diagnosis of Colorectal Neoplasms at Double - Contrast Barium Enema Examination. Levine MS et al . Radiology 2000. http://dx.doi.org/10.1148/radiology.216.1.r00jl3311 • Thoracic and Abdominal Devices Radiologists Should Recognize: Picto rial Review . Bahrami S et al . AJR 2009. http://www.ajronline.org/doi/full/10.2214/AJR.07.7146 • Imaging of Bariatric Surgery: Normal Anatomy and Postoperative Complications . Levine MS et al. Radiology 2014. http://dx.doi.org/10.1148/radiol.13122520 • Pneumatosis Intestinalis in the Adult: Benign to Life - Threatening Causes. Ho LM et al. AJR 2007. http://www.ajronline.org/doi/full/10.2214/AJR.06.1309 • Foreign Bodies . Hunter TB et al. RadioGraphics 2003. http://dx.doi.org/10.1148/rg.233025137 The UNC Health Science Library: multiple eBooks available as well electronic resources such as iAnatomy. A link to the library is provided. Sign in with your O nyen. Click on "books" at the top of the screen. You may sort by specialty: http://eresources.lib.unc.edu/external_db/external_database_auth.html?A=P|F=N|ID=222 052|REL=NA|URL=http://libproxy.lib.unc.edu/login?url=https://www.clinicalkey.com/ StatDx: f ree subscription provided by department Radiopaedia.org: free educational website, lots of cases BOOKS (most are available as eBooks through the Health Science Library. Those that are not are available in hard copy in the chest reading room): FIRST YE AR rotation: ** Mayo Clinic Gastrointestinal Imaging Review 2 ed ( 2014 ) - Great case - based book. SECOND , THIRD and FOURTH YEAR rotation: • Boland - Gastrointestinal Imaging - The Requisites, 4e (2014) • Zagoria - Genitourinary R adiology - The Requisites, 3e (2016 ) • Genitourinary Imaging : A Case Based Approach (2015) • Key Diagnostic Features in Uroradiology : A Case - Based Guide (2015) • 50 gastrointestinal cases and associated imaging (2013) REFEREN CE books: • Dunnick, Sandler, Newhouse, Amis. Textbook of Uroradiology . 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2008. • Laufer I, Levine MS. Double Contrast Gastrointestinal Radiology. (Red book), Copy in the reading roo m. Great images.