X-ray symptoms of lung lesions

Damage to the lungs and diaphragm

In acute closed or open trauma of the thorax and lungs, all victims need radiation study. The question of the urgency of its implementation and scope is decided on the basis of clinical data. The main task is to eliminate damage to the internal organs, assess the condition of the ribs, sternum and spine, and also detect possible foreign bodies and establish their localization. The importance of radiation methods is increased due to the difficulty of clinical examination of patients due to shock, acute respiratory failure, subcutaneous emphysema, hemorrhage, severe soreness, etc.

If it is necessary to carry out urgent resuscitation or surgical intervention, the radiation examination, consisting of an overview radiography of the lungs with increased voltage on the tube, is performed directly in the intensive care unit or operating room. In the absence of such urgent indications and with less severe condition of the victim, he is taken to the X-ray room where X-rays of the lungs are performed and, if possible, CT. In addition, it is advisable to perform sonography of the abdominal organs, in particular the kidneys. Pathological changes in the thoracic cavity can gradually increase, and from the 3rd to 5th of the day, a complication such as pneumonia is sometimes associated with them; therefore, if the internal organs are damaged, the radiographs of the lungs need to be repeated for several days.

Fractures of the ribs, accompanied by the displacement of fragments, are easily detected in the pictures. In the absence of bias, the detection of fractures is facilitated by the detection of parapleural hematoma, as well as by a fine fracture line in the targeted radiographs produced respectively by the pain point. The fractures of the sternum, clavicles and vertebrae are sufficiently defined. Usually compression fractures of vertebral bodies with different degree of their wedge deformation are observed.

As with open, and with closed trauma of the chest, the integrity of the lung (its rupture) can be broken.

Pathognomonic sign of lung rupture is the accumulation of gas in the pleural cavity - pneumothorax or directly in the pulmonary parenchyma in the form of a cavity - "traumatic cyst".

With simultaneous damage to the pleura, gas from the pleural cavity enters the soft tissues of the thoracic wall. Against the backdrop of these tissues and pulmonary fields, a peculiar "pinnate" pattern appears on the pictures - the result of the stratification of muscle fibers with gas. In addition, gas through the interstitial space of the lung can penetrate into the mediastinal fiber, which on the X-ray patterns manifests itself in the form of emphysema of the mediastinum.

Directly in the lung tissue can be allocated different in intensity, shape and extent of compaction sites. They represent a zone of impregnation of the parenchyma with blood, foci of edema, subsegmental and lobular atelectasis. Sometimes hemorrhages in the lung tissue manifest in the form of multiple small foci or, conversely, a single rounded hematoma.

Violation of the integrity of the shgira is accompanied by a hemorrhage. In most cases, blood accumulates in the pleural cavity, causing a picture of hemothorax. In the horizontal position of the victim, hemothorax causes a general decrease in the transparency of the pulmonary field, and in the vertical position, a darkening in its outer and lower regions with oblique upper border. Simultaneous ingress of air into the pleural cavity (with open trauma) or gas from the lung (with a rupture of the lung) causes a typical pattern of hemopneumothorax, in which the upper level of the liquid remains horizontal at any position of the body.

The wound of the diaphragm is accompanied by a high position of its damaged half and restriction of the motor function. In the case of abdominal prolapse through a defect in the diaphragm, the radiologist discovers in the thoracic cavity an unusual formation, separated from the lung tissue and adjacent to the chest-abdominal obstruction (traumatic diaphragmatic hernia). If the intestinal loops have penetrated into the thoracic cavity, this formation consists, as it were, of accumulations of gas separated by narrow septa. For such a hernia, the variability of the radiographic shadow is characteristic, and when the position of the patient's body changes and repeated studies, it is possible to establish which parts of the digestive canal have proliferated into the thoracic cavity and where the hernial gates are located: at the level of the latter there is a narrowing of the luminal gut.

Unfortunately, the trauma of the chest cavity is often complicated by the development of pneumonia, abscess, empyema of the pleura. Radiation methods - radiography, tomography, computed tomography - provide their recognition. When a bronchopleural fistula is suspected, bronchography is resorted. Scintigraphy is useful for assessing the state of capillary blood flow in the lung and the functional capacity of pulmonary tissue.

Acute pneumonia

Acute pneumonia is manifested by inflammatory infiltration of the lung tissue. In the infiltration zone, the alveoli are filled with exudate, so the airiness of the lung tissue decreases and it absorbs X-rays more than normal. In this regard, X-ray examination is the leading method of recognizing pneumonia. It allows you to determine the prevalence of the process, reactive changes in the roots of the lungs, pleura, diaphragm, timely detect complications and monitor the effectiveness of therapeutic measures.

Especially important is the radiography of the lungs with atypically clinically occurring pneumonia caused by mycoplasma, chlamydia, legionella, pneumonia in patients with immunodeficiency and nosocomial pneumonia that have arisen after surgery and artificial ventilation.

With the help of a properly conducted X-ray study, all acute pneumonia can be recognized. Inflammatory infiltration is defined as a darkening area against the background of air-filled lungs. In this area, bronchus-containing bronchi in the form of narrow light strips are often noticeable. The boundaries of the infiltrated zone are not sharp, except for that side that adjoins the inter-partic pleura.

The radiological picture of the share pneumonia is determined by the proportion of the lung that is affected. Continuous infiltration of the whole lobe is infrequent. Usually the process is limited to part of a share or one to two segments. Knowing the location of the segments, you can accurately determine the affected area. With lobular pneumonia, X-ray patterns show dimples of round or irregular shape, 1 to 2.5 cm in size, with unsharp shape, located in the background of the intensified pulmonary pattern in groups in one lung or both lungs. They can be connected to major focuses of drain pneumonia. There are also cases of small-focal pneumonia, when the acini are mostly affected. The size of the foci varies from 0.1 to 0.3 cm. In acute pneumonia, infiltration of the root fiber on the side of the lesion and a small amount of fluid in the rib-diaphragmatic sinus are often recorded. The mobility of the corresponding half of the diaphragm decreases. In the process of recovering the patient, the shadow of the infiltrated site throughout the entire length gradually weakens or disintegrates into separate small areas, between which are located restored airiness of the pulmonary lobules. X-ray changes are usually observed longer than the clinical signs of recovery, so the conclusion of a complete cure can be made on the basis of the results of a joint assessment of clinical and radiologic data. One of the adverse complications of pneumonia is purulent melting of the lung tissue with the formation of an abscess. In these cases, a cavity containing gas and liquid is determined in the infiltrate.

Thromboembolism of the branches of the pulmonary artery

Thromboembolism of the branches of the pulmonary artery occurs as a result of skidding of the embolus from the veins of the lower limbs and pelvis (especially often with thrombophlebitis or phlebothrombosis of the ileum-femoral segment of the venous system), thrombosed lower or upper vena cava, and the heart (with thromboendocarditis). Clinical diagnosis is not always reliable. The classic triad of symptoms - shortness of breath, hemoptysis, pain in the side - is noted only in 1/4 of patients, therefore, radiation research is of exceptional value.

The tactics of radiation investigation depends on the location of the thrombus and the patient's condition. In case of a threatening clinical picture with a sharp overload of the right ventricle of the heart, urgent radiography or computed tomography of the thoracic cavity organs is indicated. Signs of blockage of a large artery are an increase in the right heart, increased contractions of the right ventricle, widening of the superior vena cava, easing of the pulmonary pattern in the zone of branching of the thrombosed vessel. Perhaps the expansion of this vessel proximal to the affected area, and sometimes the "amputation" of the vessel at this level. If it is possible to perform angiography on a spiral computer tomograph or magnetic resonance angiography of the lungs, then accurately determine the size and location of the thrombus. The same data can be obtained with urgent angiopulmonography. In this case, the catheterization of the pulmonary artery is performed not only to contrast vessels, but also to perform subsequent anticoagulation and other endovascular interventions.

At a less severe condition of the patient, chest X-rays are also carried out in the first place. Consider the radiologic symptoms of pulmonary embolism: enlargement of the pulmonary artery, increase in the amplitude of contractions of the right ventricle of the heart, weakening of the vascular pattern in the affected area, lifting of the diaphragm on the same side, lamellar atelectasis in the area of reduced perfusion, a small amount of fluid in the rib-diaphragmatic sinus.

Later, in the affected area, a hemorrhagic infarction may develop. Its volume depends on the caliber of the thrombosed artery and ranges from a small focus 2-3 cm to the whole segment. The base of the compacted area is usually located subpleural, and he himself casts a triangular or oval shadow on the film. With unfavorable course, complications are possible: disintegration of tissues in the infarction zone, development of abscess and pneumonia, pleurisy.

Perfusion scintigraphy plays an important role in the recognition of thromboembolism of large branches of the pulmonary artery. Accordingly, a deficit of accumulation of RFP is detected in the area of the reduced or absent blood flow. The larger this defect, the larger the branch of the artery is affected. When embolisation of small branches, heterogeneity of the image of the lungs, presence of small lesions are noted.

Of course, scintigraphy results should be evaluated taking into account clinical and radiographic data, since similar accumulation defects can be observed in other pulmonary diseases, accompanied by a decrease in pulmonary blood flow: pneumonia, tumors, emphysema. In order to improve the accuracy of the interpretation of perfusion scintigrams, ventilation scintigraphy is performed. It allows to reveal local disturbances of ventilation in obstructive lung diseases: obstructive bronchitis, emphysema, bronchial asthma, lung cancer. However, it is with thromboembolism on vent scintigrams that there are no defects, as the bronchi in the affected area are passable.

Thus, a characteristic feature of thromboembolism of the pulmonary artery is the defect accumulation RFP on perfusion synthi-grams in a normal picture on ventilation scintigrams. Such a combination with other lung diseases is almost not recorded.

Chronic bronchitis and emphysema

Chronic bronchitis is a group of common diseases in which there is a diffuse inflammatory lesion of the bronchial tree. There are simple (uncomplicated) and complicated bronchitis. The latter is manifested in three forms: obstructive, mucopurulent and mixed bronchitis.

In the diagnosis of simple bronchitis, radiation methods are not of great importance, and the main role is played by fibrobronchoscopy. The task of the radiologist is primarily to exclude other lung lesions, which can cause similar clinical signs (pulmonary tuberculosis, cancer, etc.). On the radiographs there is only an increase in the pulmonary pattern, mainly in the lower parts, due to the thickening of the walls of the bronchi and peribronchial sclerosis. Quite another matter is the recognition of obstructive forms of bronchitis, in which the results of X-ray and radionuclide studies serve as an important supplement to clinical data. On radiographs, tomograms and computer tomograms with obstructive bronchitis, there are three groups of symptoms:

1. increased connective tissue volume in the lungs;
2. emphysema and pulmonary hypertension;
3. relatively small size of the heart.

The increase in the volume of connective tissue is expressed primarily in the thickening of the walls of the bronchi and peribronchial sclerosis. As a consequence, in the pictures, bronchial clearances, bordered by a narrow shadow strip (a symptom of "tramway rails"), loom, especially in the basal zones. If these bronchi are reflected in the axial section, then they stand out as small ring-shaped shadows with an external uneven contour. In connection with the development of fibrous tissue, the pulmonary pattern takes on a mesh appearance. As a rule, fibrotic deformation of the roots of the lungs is also found. The narrowing of the lumen of the small bronchi leads to the development of diffuse emphysema of the lungs and pulmonary hypertension. An x-ray picture of these conditions was described above. The displacement of the ribs and the diaphragm during breathing decreases, as do the differences in the transparency of the pulmonary fields on inspiration and expiration; the area of pulmonary fields is increased.

The radiological picture of obstructive bronchitis is so characteristic that usually there is no need for special contrasting of the bronchi - bronchography. Bronchographic symptoms of bronchitis are diverse. The most important of these are the penetration of the contrast medium into the enlarged estuaries of the bronchial glands (adenectasis), the deformation of the bronchi with uneven contours, bronchial spasms in the area of their mouth or throughout, the failure of small branches, the presence of small cavities (cavities), congestion of sputum in the lumen of the bronchi, causing various defects in accumulation of RFP in the shadow of the bronchi.

With lung scintigraphy, in addition to the increase in pulmonary fields and a general decrease in accumulation of RFP, defects in its distribution are often noted. They correspond to areas of disturbed blood flow and ventilation - emphysematous blisters and bulls. Very clearly emfizematoznye cavities on computer tomograms.

Chronic pneumonia and limited nonspecific pneumosclerosis

X-ray examination allows you to recognize all forms and stages of the course of chronic pneumonia. The pictures determine the infiltration of the lung tissue. It causes a non-uniform darkening due to a combination of infiltration and sclerosis, coarse fibrous cords, bronchial lumens bordered by a band of peribronchial sclerosis. The process can capture part of the segment, part of the share, a whole fraction or even the entire lung. In the shadow of the infiltration, separate cavities containing liquid and gas can be seen. The picture is supplemented with fibrotic deformity of the lung root and pleural layers around the affected lung.

However, the doctor always faces the danger of taking for a chronic pneumonia a limited nonspecific pneumosclerosis that occurs as a result of a transferred pneumonia, which resulted in not complete resolution of infiltration, but the development of a fibrous (cicatricial) field. X-ray diffraction patterns also determine the inhomogeneous darkening caused by a combination of sclerosis sites and emphysema lobule. The changed section of the lung is diminished, intertwining cords of fibrous tissue are distinguishable, between which are rosette-like light areas - swollen lobules, but unlike pneumonia there are no infiltration foci and, especially, small purulent cavities, the outlines of all shadow elements are sharp, not vague. On repeated pictures the picture does not change. There are no clinico-laboratory signs of a chronic inflammatory process, except for signs of regional bronchitis, which is sometimes exacerbated in areas of pneumosclerosis.

In order to get an idea of the state of the bronchial tree in chronic pneumonia and bronchiectasis, a computer tomography is performed, and only if it is impossible to perform it, one resorts to bronchography. According to bronchograms, it is possible to distinguish between bronchial changes in these diseases. Chronic pneumonia is characterized by an unusual pattern. Changes in the bronchi in the infiltration zone are not uniform, their outlines are uneven, the areas of constriction and expansion are of different sizes. With congenital bronchiectasis, on the contrary, the radiographs of different patients seem to copy one another. Cystic bronchiectasis causes multiple thin-walled cavities that do not contain liquid. Pulmonary tissue to the periphery of the cavities is underdeveloped, without foci of infiltration, the pulmonary pattern is impoverished ("cystic lung hypoplasia"). With dysontogenetic bronchiectasises, the part of the lung is underdeveloped and reduced (for example, the entire lower lobe). Bronchi in it are collected in a bundle, equally expanded and terminated with clavate swellings.

Pneumoconiosis

With the modern development of industrial and agricultural production, the problem of prevention and early recognition of pulmonary lung lesions - pneumoconiosis - has acquired exceptional significance.

The main role here, of course, is played by x-ray research. Of course, the diagnosis is based primarily on data on the patient's long-term work in conditions of high content of inorganic and organic dust in the air, but anamnestic information does not always help.

Professional experience may be small, and the reliability of anti-dust measures in production is insufficient. Even more insidious are cases when the worker of the dust profession develops not pneumoconiosis or not only pneumoconiosis, but also other disseminated lung lesions. Clinical manifestations of pneumoconiosis in early stages are scarce.

Early, like all subsequent diagnostics of pneumoconiosis, is based on the results of analysis of high-quality x-ray images. Depending on the nature of the dust and the reactivity of the patient's body, the first subtle symptoms are expressed mainly in interstitial or focal changes, therefore three types of disease are distinguished: interstitial, nodular and nodular.

The interstitial type is initially manifested by the gentle retina of the pulmonary pattern in the basal zones. Gradually, the densification of the interstitial tissue and, accordingly, the restructuring of the pulmonary pattern spread along the pulmonary fields with a certain tendency to spare the apices and the bases of the lungs. However, with asbestosis and talcose, the pattern of the pattern is mainly observed in the lower parts. Focal formations with asbestosis are absent, but there are pleural layers, sometimes powerful, in which there may be lime deposits. Interstitial changes predominate in pneumoconiosis of grinders, aluminosis, inhalation of tungsten and cobalt dust, anthracosis.

The unfolded picture of silicosis and pneumoconiosis of miners is characterized by the presence of multiple foci against the background of diffuse mesh fibrosis, i.e. There is a nodular type of disease. Pneumoconiotic nodules are caused by proliferation of connective tissue around dust particles. The dimensions of the foci are different - from 1 to 10 mm, the shape is irregular, the outlines are uneven, but sharp. They are more densely located in the middle and lower divisions. The roots of the lungs are enlarged, fibrously compacted, lymph nodes can be enlarged in them (the marginal, shell-like calcification of such nodes is very indicative). The peripheral parts of the lungs are swollen. Sign of increasing pressure in the small circle is the expansion of large branches of the pulmonary artery, small dimensions of the heart shadow, hypertrophy of the right ventricular muscle, deepening of its contractions. Further progression of the disease leads to the formation of large fibrous fields and compaction sites (large dimming). This is the nodal type of lesion. Recognizing it is not difficult. It is only necessary to exclude the often observed combination of conglomerate pneumoconiosis with pulmonary tuberculosis.

Pulmonary tuberculosis

The basis of all measures to combat tuberculosis is the principle of preventing infection and early recognition of the disease. The objectives of early detection are testing fluorographic examinations of various contingents of a healthy population, as well as correct and timely diagnosis of tuberculosis in outpatient clinics, polyclinics and hospitals of the general medical network. In accordance with this classification, the following forms of tuberculosis of the respiratory system are distinguished.

Primary tuberculosis complex. Tuberculosis of the intrathoracic lymph nodes. Disseminated tuberculosis of the lungs. Miliary tuberculosis of the lungs. Focal pulmonary tuberculosis of the lungs. Infiltrative pulmonary tuberculosis. Caseous pneumonia. Tuberculoma of the lungs. Cavernous tuberculosis of the lungs. Fibrous-cavernous pulmonary tuberculosis. Tuberculous pleurisy (including empyema). Tuberculosis of the upper respiratory tract, trachea, bronchi, etc. Tuberculosis of the respiratory system, combined with pulmonary diseases of the lungs.

There are two phases of tuberculosis:

• infiltration, decay, seeding;
• resorption, compaction, scarring, calcification.

As can be seen, the clinical classification of pulmonary tuberculosis is based on the morphological data revealed by X-ray examination.

Primary complex.

The objectives of X-ray examination in the examination of patients with pulmonary tuberculosis:

• 1) establish the presence of the tuberculosis process in the lungs;
• 2) characterize the morphological changes in the lungs and hilar lymph nodes;
• 3) determine the form and phase of the disease;
• 4) monitor the dynamics of the process and the effectiveness of therapy.

Primary tuberculosis complex is an ochagacinous or lobular pneumonia, usually located subpleurally. From it to the root of the lung stretch narrow strips of lymphangitis. In the root, the enlarged lymph nodes are determined - a characteristic sign of primary tuberculosis. The shadow seen in the pictures in the pulmonary field consists of a central curd and a perifocal zone, which is caused by serous lymphocytic impregnation of tissues. Under the influence of specific therapy, the perifocal zone decreases by the end of the 3-4th week and resolves for 3-4 months. The lymph nodes gradually decrease, become denser. For 2-3 years in the pulmonary focus and lymph nodes lime salts are deposited. The calcified primary focus was called the Gon focus. It is found in X-ray screening tests in 10-15% of healthy people.

Tuberculosis of the intrathoracic lymph nodes is the main form of intrathoracic tuberculosis, observed in childhood. Radiograms determine the increase in one or both of the roots of the lungs and the loss of differentiation of their shade. In some cases, enlarged lymph nodes appear at the root, in others their outlines are lost in the shadow of perifocal infiltration. The diagnosis of lymph node hyperplasia is assisted by tomography, especially computer tomography. With the healing of the nodes are reduced, at the root remain fibrous changes.

Disseminated pulmonary tuberculosis occurs in various forms (miliary, acute and chronic disseminated), and the dissemination of foci can occur by hematogenous or bronchogenic pathways.

In acute hematogenically disseminated tuberculosis, pulmonary fields are defined by multiple uniformly distributed uniform focal shadows. The lungs are moderately swollen at the same time, but their transparency is reduced, and the pulmonary pattern is partially hidden behind the focal stratum.

Chronic hematogenous-disseminated tuberculosis is characterized by a wave-like course with repeated eruption and partial resorption of the foci. It is characterized by a bilateral defeat of the tops and dorsal parts of the upper lobes. Foci are diverse in size, plural, usually productive. They are located on the background of an intensified pulmonary pattern (due to fibrosis). Fusion of foci and their decay lead to the appearance of thin-walled caverns. They serve as a source of bronchogenic colonization - the appearance of acinous or lobular foci of compaction of pulmonary tissue in the middle and lower parts of the lungs.

Focal tuberculosis - this is actually a group of different in the genesis of tuberculosis lesions of the lungs after the primary period. Their distinctive feature is the presence of unevenly and asymmetrically located foci of different shapes and sizes, mainly in the apices and subclavian parts of the pulmonary fields. On the anterior radiograph the total extent of the lesion should not exceed the width of the two intercostal spaces (not counting the tops), otherwise they are not talking about the focal, but about the disseminated process.

Infiltrative pulmonary tuberculosis is shown on radiographs as a typical limited darkening of the pulmonary field. The substrate of blackout is perifocal inflammation around the newly formed or exacerbated old tuberculosis focus. The length and shape of the shading vary widely: it is a round focus in the subclavian zone, then a large cloud-shaped shadow corresponding to any subsegment or segment, then infiltration of the lung tissue near the interlobar fissure (the so-called pericissuritis: from the "scissure" - the interlobar slot) . The dynamics of infiltration is different. In favorable cases, perifocal inflammation completely resolves, and the caseous center becomes denser. In the pictures there remains a small fibrous field or compacted focus, but the infiltration melts with the formation of a cavity. Sometimes all the infiltration is subjected to a curdled regeneration, encapsulated and transformed into tuberculoma.

Caseous pneumonia belongs to severe forms of tuberculous lesion. It is characterized by infiltration of a whole lobe of the lung with a rapidly emerging caseous decay and the formation of cavities or the appearance of multiple lobular foci, also prone to fusion and disintegration.

Tuberculoma of the lungs is one of the variants of the progression of the pulmonary focus or infiltrate. The roentgenogram shows a rounded, oval or irregular shape with a sharp and slightly uneven contours. The shadow is intense, sometimes lighter parts of the decay of the semilunar form or more dense inclusions are deposited in it - lime deposits. In the pulmonary tissue around the tuberculoma or at a distance from it, shadows of tuberculosis foci and post-tuberculosis scars can be seen, which helps in differential Diagnosis with primary lung cancer.

Cavernous tuberculosis of the lungs arises as a consequence of the disintegration of lung tissue in any forms of tuberculosis. Its characteristic radiographic character is the presence of an annular shadow in the pulmonary field. Sometimes the cavity clearly looms on the survey or sighting radiographs. In other cases, it is hardly distinguishable from the shadow of tuberculosis foci and sclerosis of lung tissue. In these cases, tomography helps. With fresh cavernous tuberculosis sclerotic phenomena are usually minor, but later the wrinkling of affected areas begins, which are riddled with coarse strands and contain numerous tuberculous foci: the process passes into the phase of cirrhosis.

Cirrhotic tuberculosis of the lungs is the final stage of the progression of tuberculosis, accompanied by the disintegration of lung tissue. The affected part of the lung, most often the upper lobe, is sharply reduced, sclerotized. Its shadow in the images is heterogeneous due to a combination of sclerosis sites, deformed tuberculous caverns, dense foci, individual swellings of lung tissue. The organs of the mediastinum are biased towards the lesion, the intercostal spaces are narrowed, there are pleural layers, adjacent sections of the lung are swollen.

Primary lung cancer

Primary lung cancer in the early phases of development does not give distinctive subjective symptoms and a clear clinical picture. The mismatch of clinical manifestations of the disease and anatomical changes is the reason that the patient does not consult a doctor. On the path of the disease there must be a barrier - a mass survey of the population using fluorography or roentgenography. Every year contingents are subject to an annual survey, in which lung cancer most often develops: smokers are over 45 years old and persons suffering from chronic lung diseases. In all patients who have fluorograms or roentgenograms detected changes in the lungs, it is necessary first and foremost to exclude cancer.

The main methods of X-ray diagnosis of primary lung cancer are lung radiography in two projections with high voltage on the tube and tomography or CT of lungs. With their help, you can find both major forms of cancer - central and peripheral.

Central cancer comes from the epithelium of segmental, lobar or main bronchus. In the early phase, the image of the tumor is difficult to see because of its small size and a large number of shadows in the root of the lung, therefore, with small hemoptysis of an unclear nature or an unexplained cough lasting more than 3 weeks, bronchial examination is indicated. Then, with predominantly endobronchial tumor growth, symptoms of ventilation and blood flow disturbance appear in the segment or lobe associated with the bronchus, whose lumen is narrowed by the tumor. The radiological picture of these disorders - hypoventilation, obstructive emphysema and atelectasis - is described above. In these cases, a tomography or CT scan is performed. The slightest narrowing of the bronchus, the unevenness of its contours, an additional shadow in the lumen confirm the assumption of the tumor process.

With predominantly exobronchial tumor growth and local thickening of the bronchus wall, the shadow on the tomograms appears relatively early, and then, when its size exceeds 1-1.5 cm, it becomes noticeable on X-rays. Similar signs are observed with peribronchial knotty cancer. Conversely, with branched peribronchial cancer, the image of the tumor node is absent. In the basal zone, the area of the intensified pattern is determined, composed of sinuous strips radiating radially into the pulmonary field and accompanying the vascular-bronchial branching. The root shadow is poorly differentiated. On the tomograms you can see the narrowing of the lumen of the lobar or segmental bronchus and the branches that branch out from it. When scintigraphy, a clear violation of blood flow in the pulmonary field is revealed. In the end, with all variants of the growth of the central cancer, there is atelectasis of the segment, lobe or entire lung.

Radiological expression of small peripheral cancer is a single focus in the lung. Its features are as follows:

1. a small value (the limit of discernibility on a fluorogram is 4-5 mm, on a roentgenogram of 3 mm);
2. low shadow intensity (even at a diameter of 10-15 mm this shadow is weaker than the shadow of tuberculoma or benign tumor);
3. round form; Shadows of a triangular, diamond-shaped and star-shaped form are also less common;
4. relatively blurred contours (also in comparison with the shadow of the cyst or benign tumor).

Lime inclusions are observed rarely - only in 1% of cases of peripheral cancer.

As the tumor grows, its shadow becomes more rounded, but its edges are more scalloped or just bumpy, which is well defined in linear and computer tomograms. Characteristic is also a more pronounced unevenness at any one site and an entrainment on the contour in the place where the bronchus enters the tumor. The shadow of the tumor is non-uniform, which is explained by the tuberosity of its surface. In the event of disintegration, enlightenment appears in the shadow of the tumor. They can look like two or three small cavities or one large edge or centrally located cavity. Known and the so-called cavitary form of cancer, when in the images looms a round cavity resembling a cavern or cyst. The cancerous nature of it gives an unevenness of the inner surface and a tuberous thickening in a limited area of one of the walls of the cavity (the symptom of "ring with a ring"). For tumors with a diameter of more than 3-4 cm, "pathways" to the pleura and root of the lung are often determined.

In the presence of radiographs, performed at different times, you can set an approximate rate of tumor growth. In general, the doubling of its volume varies from 45 to 450 days. In the elderly, the tumor can grow very slowly, so that its shadow is almost unchanged for 6-12 months.

Valuable information is obtained with CT. It allows you to clarify the prevalence of central cancer, its growth in the organs of the mediastinum, the state of the intrathoracic lymph nodes, the presence of effusion in the pleural cavity and pericardium. With a peripheral node in the lung, CT allows the exclusion of benign tumors containing areas of fat or ossification (in particular, hamartomas). The density of the cancer node exceeds 60 HU, but if it is more than 140 HU, it is usually a benign tumor. According to the tomograms, the sprouting of the peripheral cancer into the rib is very clearly traced. In addition, cancerous nodules are detected, which in normal pictures are not easily seen (in the near-diastinal or marginal subpleural zones).

An auxiliary method in the diagnosis of lung cancer and its metastases in the mediastinal lymph nodes is scintigraphy with gallium citrate. This RFP has the ability to accumulate both in the nodes of cancer, and in clusters of lymphoid tissue with lymphogranulomatosis, lymphosarcoma, and lymphocytic leukemia. The property of concentrating in a cancerous tumor of the lung is also possessed by the technetium preparation - 99mTc-sesambi.

In almost all cases of operable cancer, bronchoscopy or transthoracic puncture is necessary to obtain a piece of tissue for its microscopic examination. Under the control of television fluoroscopy, it is possible to puncture most pulmonary and mediastinal formations, but in some cases, when it is difficult to get into a small "target" and choose the optimal trajectory of needle movement, the puncture is performed under CT control. A thin biopsy needle is inserted along a linear cursor. Using several slices, it is determined that the end of the needle is in the correct position.

Many malignant tumors (lung cancer, breast cancer, seminoma, osteogenic sarcoma, etc.) are prone to metastasizing into the lungs. The picture is quite typical, when several or many rounded tumor nodules are revealed in the lungs. It is more difficult to diagnose cancer lymphangitis, when sinuous streaks seem to penetrate the lower parts of the pulmonary fields. This lesion is especially characteristic for lung cancer metastasis of the stomach.

Diffuse (disseminated) lung injury

By diffuse (disseminated) lung lesions, the common changes in both lungs are understood as the scattering of foci, the increase in the volume of interstitial tissue, or a combination of these conditions.

Among the frequently observed focal lesions are all forms of disseminated tuberculosis, lung carcinomatosis, acute bronchiolitis, childhood infections.

On radiographs, linear and computer tomograms, multiple single-type or different-caliber foci in both lungs are determined. Depending on the size of the foci, miliary seeding is distinguished (foci 0.5-2 mm in size), shallow focal (2-4 mm), medium-focal (4-8 mm) and large-focal (more than 8 mm).

The increase in the volume of the interstitial lung tissue is expressed on the radiographs in the enhancement of the pulmonary pattern, which takes the form of a tender or coarser mesh. Previously, this reticular restructuring of the lung structure is detected on computer tomograms. They can judge the state of interlobular septa, the presence of peribronchial seals, exudate in the alveolar tissue, lobular emphysema, small granulomatous nodules. Frequently revealed reticular-nodular lesions include pneumoconiosis, sarcoidosis, exogenous and endogenous allergic alveolitis, toxic alveolitis, drug disease, cancer lymphangitis and all forms of idiopathic fibrosing alveolitis, including the Hammain-Rich syndrome.

According to the X-ray data, the nature of the diffuse lesion can not be established in all cases. Crucial is the comparison of the results of the survey and examination of the patient, radiation studies (radiography, CT, scintigraphy with gallium citrate), bronchoalveolar lavage, immunological tests.

Pleurisy

In the pleural cavity of a healthy person contains 3-5 ml of a "lubricant" liquid. This amount is not detected by radiotherapy. When the volume of the liquid increases to 15-20 ml, it can be detected by ultrasound. Thus the patient should be in a position lying on a sick side: then the liquid will accumulate in the lowest (outer) part of the pleural cavity, where it is determined.

In the same way, a small amount of free pleural fluid is detected during radiography, taking pictures in the position of the patient on the side (laterography) on exhalation. With further accumulation of fluids, her X-ray diagnosis is not difficult.

Any free effusion in the pleural cavity on radiographs produced in a direct projection in the vertical position of the patient causes an intense shadow in the lower-right section of the pulmonary field of approximately triangular shape. The shadow is adjacent to the ribs and diaphragm by two sides, and from above it descends from the side of the chest to the diaphragm. The upper boundary is not sharp, as the layer of liquid upward gradually becomes thinner. As the effusion accumulates, the size and intensity of the shadow increase. When the upper border of the effusion is at the level of the lateral part of the body V of the rib, its quantity is equal to 1 liter on the average, 1.5 liters at the IV edge, and 2 liters of the 3rd rib. The more effusions, the more the mediastinum organs are pushed in the opposite direction.

In the presence of joints that separate the pleural cavity into separate chambers, limited (encysted) effusions are formed. Sealed in pleural sheets, they do not shift when the position of the body changes and slowly dissolves. The boundaries of the shadow become viscous and convex when they are viscous. Shape and position of the shade are determined by the place of fluid entrapment - near the ribs (costal effusion), between the diaphragm and the base of the lung (diaphragmatic), near the mediastinum (mediastinal), in the interlobar fissure (interlobar).

Voluminous formations in the mediastinum

In the mediastin reveal a variety of cystic, tumor and tumor-like formations, mainly in the radiographic examination of the thoracic cavity. Radiography and CT usually allow to clarify the location of pathological education, which in itself is very important for diagnosis.

In the anterior mediastinum, mainly the retrosternal goiter, thymoma, teratomas, aneurysm of the ascending aorta, packets of enlarged lymph nodes are localized. The enlarged lymph nodes can also be located in the middle part of the mediastinum. Aneurysm of the aortic arch and bronchogenic cyst can also be detected there. In the posterior mediastinum, neurogenic tumors and cysts, enterogenic cysts, aneurysm of the descending part of the thoracic aorta are detected. In addition, part of the stomach penetrates into the region of the posterior mediastinum with a hernia of the esophageal opening of the diaphragm.

Differential diagnosis of all these multiple lesions is based on history, clinical examination, laboratory tests and, of course, radiation studies and biopsies. Let us point out the main points. With the help of CT and MRI, aneurysms of the aorta and other large vessels are easily recognized. These same methods and ultrasound can establish the tissue structure of the formation and thereby diagnose fluid-filled cysts and teratomas that include fat or bone elements. If suspected of a chest or intestinal goiter, it is advisable to start the examination with scintigraphy with ^99m Tc-pertechnetate or radioactive iodine, which accumulate in the thyroid gland. As for lymphadenopathy, its nature is determined based on the history and results of clinical and laboratory research. At the heart of lymphadenopathy in adults are more often such diseases as lymphomas (including lymphocytic leukemia), sarcoidosis and metastases of cancer, less often - tuberculosis and infectious mononucleosis.

At present, puncture biopsies under ultrasound guidance are widely used to establish the final diagnosis, either under the control of CT or X-ray television.

Intensive therapy and intervention intervention under the control of radiation methods

As already noted above, sonography, X-ray television, CT and MRI are widely used as methods of guidance and control in the puncture biopsy of pulmonary and mediastinal formations, as well as for the drainage of abscesses and empyema of the pleura. When hemoptysis and bleeding are embolization of the corresponding bronchial artery. Embolization of pulmonary vessels is used to treat arteriovenous malformations in the lungs.

Radiation control is necessary for the catheterization of vessels, in particular for establishing the position of the central venous catheter and excluding the extraluminal spread of the solution. The introduction of a catheter into the subclavian vein is sometimes accompanied by the development of pneumothorax or mediastinal hematoma. These complications are recognized by radiography. To detect a small pneumothorax, a snapshot of the lungs is performed with a deep expiration. The position of the catheter (probe) is also recorded when measuring central venous pressure in the pulmonary artery.

Pulmonary complications are observed after various surgical operations. In the intensive care unit, the radiologist usually has to differentiate four pathological conditions of the lungs: edema, atelectasis, pneumonia and aspiration. The manifestations of the interstitial edema resemble the picture of venous stasis in the lungs, the alveolar edema causes unclearly delimited "blackouts" in the pulmonary fields, especially in the basal zones and in the lower regions. Falling of a share or a segment can be the result of postoperative collapse, secretion delay in the bronchial tree or aspiration. Diskovidnye or lamellar atelectasis have the form of narrow strips, intersecting the pulmonary fields mainly in the supra-diaphragmatic zones. Aspiration of the contents of the stomach leads to the appearance of focal shadows of different sizes in the lower parts of the lungs

After trauma and severe operations, there is sometimes a microcirculation disorder in the lungs with a picture of the so-called respiratory distress syndrome ("shock lung"). Starting with the phenomena of interstitial edema, it then causes large areas of alveolar edema.

After removing the lung on the radiographs, a drainage tube appears, lying in the empty pleural cavity. This cavity is gradually filled with liquid, and during the roentgenological examination, hydropneumothorax is found. As the fluid dissolves, pleural moorings are formed and fibrothorax is formed.

During the first 24 hours after lung transplantation, pulmonary edema occurs. In the next 2-3 days he resolves. Delayed resorption of the edema or its build-up gives reason to suspect acute lung rejection. In this case, there is also a pleural effusion. A severe complication is stenosis of the vascular-bronchial anastomosis, which can lead to necrosis of its wall, in connection with which many patients are required to perform dilatation and stenting of the narrowed section. Almost half of the patients after lung transplantation have infectious complications - bronchitis, pneumonia. A terrible symptom of a possible chronic rejection of the lung is the development of constrictive bronchiolitis, which is accompanied by atelectasis, the development of bronchiectasis and fibrosis areas. It is determined with the help of CT after 3 months after transplantation.