Digital X-ray: Not so indefectible!

Digital X-ray has taken over and replaced conventional radiography in a huge way. There are several advantages of digital radiography including reduced radiation exposure (effective doses for direct digital radiography are up to 29% lower than those for screen-film radiography),[1] better X-ray image quality,[2] image enhancement is possible like the exposure of each image can be adjusted, and enlargement of images is possible. It has also eliminated the need to file and store hard-copy radiographic images and there is less likelihood of losing digital data. No dealing with harmful developing chemicals and fixing solutions for developing film is required. X-ray images are instantly stored and ready to view on computer, and these images can also be electronically distributed to numerous locations.[3]

However, amidst all the advantages lies the major disadvantage of the ease with which electronic images can be modified. It arouses the suspicion that they could be adulterated either purposefully or by mistake very easily. We report one such incidence of post-acquisition modification of the X-ray film that could have changed the diagnosis of the patient altogether. A 23-year old female patient was referred to our institute, a case of situs inversus dextrocardia with ostium secundum atrial septal defect (OS-ASD), for closure of ASD. The patient had a conventional chest radiograph film taken elsewhere showing situs inversus dextrocardia. Patient underwent routine blood investigations in our institute along with digital chest radiograph. This chest radiograph was inverted digitally, and print was given to the patient which showed situs solitus levocardia [Figure 1]. After the patient underwent echocardiography, the diagnosis was confirmed to be dextrocardia with situs solitus and chest X-ray was repeated with clear instruction to keep marker while taking the film [Figure 2].

Figure 1

Post modification X-ray film

Figure 2

Repeat chest X-ray film with the marker without modification

This is one example of how digitalization has its limitations and disadvantages as well. Not only it adds confusion for the diagnosis of a patient, but it also has legal implications if such modifications are used for medical malpractice.

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