ABDOMINAL RADIOGRAPHS

DR. JAYA SELVI NAGENDRAN

JABATAN PENGIMEJAN DIAGNOSTIK
HOSPITAL PULAU PINANG

Acknowledgement to Dr Salwah Hashim

 LECTURE OUTLINE

INTRODUCTION
PATTERN RECOGNITION
INTERPRETATION
 AXR vs KUB

KUB till the AXR includes the

symphysis pubis hemidiaphragm
1. 11th rib
2. Vertebral body (T12)
3. Gas in stomach.
4. Gas in colon (splenic
flexure).
5. Gas in transverse colon
6. Gas in descending
colon
10.Gas in caecum
12.Gas in colon (hepatic
flexure).
13. Psoas margin.
Renal shadow
What to Examine

1. GI pattern
2. Extraluminal air
3. Calcifications
4. Soft tissue masses
1. GIT GAS PATTERN,
AIR FLUID LEVELS,
BOWEL CALIBRE
 Normal Gas Pattern

l Stomach
n Always

l Small Bowel
n Two or three loops of non-distended bowel
n Normal diameter = 2.5 cm

l Large Bowel
n In rectum or sigmoid almost always
 Gas in
stomach

Gas in a few
Gas in large
loops of
bowel
small bowel

Gas in
Gas in rectum or
large bowel sigmoid

Normal Gas Pattern

Normal Fluid Levels

l Stomach
n Always (except supine film)

l Small Bowel
n Two or three levels possible

l Large Bowel
n None normally
 Always
air/fluid level
in stomach

A few
air/fluid
levels in
small bowel

Normal Fluid levels

Abnormal multiple air fluid levels at different levels
 Bowel calibre
Jejunum is dilated > 3.5 cm
Ileum > 2.5 cm
Caecum > 8 cm.
Transverse colon > 5.5 cm

Dilated jejunum has valvulae coniventes

Colon has haustration

 Large vs. Small Bowel

l Small Bowel Large Bowel

n Central n Peripheral
n Valvulae extend across n Haustral markings interdigitate and
the diameter of the jejunum do not cross the diameter of colon
Abnormal Gas Patterns

l Functional Ileus
n Localized (Sentinel Loops)
n Generalized adynamic ileus

l Mechanical Obstruction
n Small bowel obstruction
n Large bowel obstruction
 Localized Ileus
Key Features
1. One or two persistently dilated loops of large or small bowel
2. Gas in rectum or sigmoid

Supine Prone
Sentinel Loops
Cholecystitis Pancreatitis
Ulcer

Appendicitis Diverticulitis

Ulcer
Ureteral calculus
 PARALYTIC ILEUS :
In paralytic ileus, there is temporary impedance to
the passage of air or contents secondary to
uncoordinated peristalsis or hypoperistalsis

Features on AXR
usually shows no preferential collection of air.
Air in both the small and large bowel.
 Generalized Ileus
Key Features
1. Gas in dilated small bowel and large bowel to rectum
2. Long air-fluid levels
3. Mostly post-op patients have generalized ileus
 MECHANICAL ILEUS (Obstruction)

A mechanical ileus is an impedance to the passage

of air or intestinal contents secondary to a
mechanical obstruction
Features on AXR :
1. Preferentially more air proximal to the obstruction
than distal to it
2. A gasless abdomen (highly suggestive of a high
obstruction)
 Mechanical SBO

Key Features
1. Dilated small bowel
2. Little gas in colon,
especially rectum
3. Key:
disproportionate
dilatation of SB
Mechanical SBO

Causes

1. Adhesions
2. Hernia
3. Volvulus
4. Gallstone ileus
5. Intussusception
 Mechanical LBO
Key Features
1. Dilated colon to
point of obstruction
2. Little or no air in
rectum/sigmoid
3. Little or no gas in
small bowel, if
Ileocecal valve
remains competent
Mechanical LBO

Causes
1. Tumor
2. Volvulus
3. Hernia
4. Diverticulitis
5. Intussusception
A gasless abdomen
(highly suggestive of a
high obstruction)
 When the dilated intestinal loops are filled with fluid, the
loops may be isodense with the rest of the abdomen,
showing a paucity of gas.
On the erect view, the air may get trapped in the valvulae
connivantes giving a "string of pearls appearance.
To determine from AXR if mechanical
(obstruction) or paralytic ileus, look at:
1. Distribution of gas
2. Dilatation of bowel
3. Presence of air-fluid levels
4. Arrangement of the loops of bowels
 1. Distribution of gas
Obstruction:
Gasless / poor gas distribution OR
too much air in the small bowel / too much air in
the large bowel
Ileus:
Good gas distribution over most of the abdomen
Too much air in both large and small bowel
NOTE: This could also appear in large bowel
obstruction with an incompetent ileocaecal valve, or
in an early or intermittent small bowel obstruction
 2. Bowel dilatation
Obstruction:
Bowel walls are smooth ( bowels resemble
sausages or a hose). Preferential dilatation of
the bowel proximal to the obstruction
Ileus:
Proportional dilatation of the bowel, so that the
colon remains larger than the small intestine
 3. Air-fluid levels (erect view)
Obstruction:
Many dilated air-fluid levels in both limbs of a given
loop, at different heights (resembling candy canes)
Ileus:
Fewer and / or smaller (less dilated) air-fluid levels
scattered throughout the abdomen
Small air-fluid levels are most often indicative of an
ileus, large air fluid levels with J-shaped loops (candy
cane appearance) are more suggestive of a bowel
obstruction
 4. Arrangement of loops
(supine view only)
Obstruction:
Dilated loops arranged in an orderly
"stepladder" fashion. A bag of sausages
Ileus:
Dilated bowel arranged disorderly scattered
throughout the abdomen. A bag of popcorn
Sausages Candy canes Step ladder

Small Bowel obstruction

 Dilated bowel
arranged
disorderly
scattered
throughout the
abdomen.

R
SUPINE

Paralytic ileus
 CASE 1

R SUPINE R ERECT

17 days old male; abdominal distension, vomiting

Gas Distribution: There are loops of bowel mostly in the
central abdomen - The dilated loops are mostly small bowel
Bowel Dilatation: The bowel walls are smooth - indicating
that the bowel is obstructed
Air-Fluid Levels: There are multiple air fluid levels on the
upright film
Arrangement of Loops: Orderly, although not truly in a
stepladder fashion. The arrangement here resembles a bag
of sausages rather than a bag of popcorn
R SUPINE R ERECT

Impression: Small bowel obstruction.

CASE 2

SUPINE
R SUPINE
R

5 day old female; abdominal distension, fever

Gas Distribution: Generalized presence of gas
throughout all quadrants both large and small bowel
dilated.
Bowel Dilatation: The degree of bowel dilatation is
proportional (LB more dilated than SB, thought both
dilated). Haustra and plicae are well preserved.
Air-Fluid Levels: None
Arrangement of Loops: Disorderly arrangement
resembling a bag of popcorn
 R
SUPINE

Impression: Ileus (Underlying cause gastroenteritis)

CASE 3

R R
SUPINE SUPINE
Gas Distribution: There are pockets of gas scattered in
several areas of the abdomen. There is gas in the small
bowel, colon and rectum
Bowel Dilatation: No excessively dilated bowel. The bowel
walls are not smooth. Valvulae and haustra are preserved
Air-Fluid Levels: None
Arrangement of Loops: Large loops are not present. No
particular order of loops
 R
R SUPINE SUPINE

Impression : Normal AXR

MALROTATION & VOLVULUS
 Gasless abdomen except
for the small air bubble in
the stomach

R SUPINE
High GI obstruction
R SUPINE

Sigmoid volvulus dilated double loop

(coffee bean shaped) loop of sigmoid colon,
apex in the pelvis, directed to the RHC)
INTUSSUSCEPTION
 AXR
Radiographic signs that may be seen in intussusception:
a. Soft tissue mass: An absence of bowel gas in the area
suggesting indirectly that something is pushing normal
bowel out of the way. Target sign, crescent sign
b. Small bowel obstruction: Dilated bowel loops and air-
fluid levels. Smooth bowel walls lacking normal
haustrations
c. Paucity of gas: Distal to obstruction
AXR may be normal. There may only be evidence of
bowel obstruction after 6-12 hours of symptoms.Thus,
plain abdominal films cannot be used to rule out
intussusception
Signs of intussusception on a plain Xray include:
1. Paucity of gas in RIF
2. Small bowel obstruction
3. Target sign - 2 concentric circular radiolucent lines usually in the
right upper quadrant
4. Crescent sign - a crescent-shaped lucency usually in the left upper
quadrant with a soft tissue mass
Soft-tissue density mass of
the intussusceptum
projecting into the colon
(leading edge)
If the head of the
intussusceptum is projecting
into a gas filled pocket, it will
show itself
It can take on a crescent
shape or may also merely
resemble a protruding head
into a gas filled pocket
L
2. EXTRALUMINAL AIR
 ABNORMAL EXTRALUMINAL
GAS PATTERNS
1. Pneumoperitoneum
2. Retroperitoneal free air
3. Air in the bowel wall (intramural air)
4. Air in the portal venous system
5. Air in the biliary tract (aerobilia)
 Pneumoperitoneum
(free intraperitoneal air)
1.Usually signifies GIT perforation (abdominal
trauma, inflammatory conditions, foreign body
ingestion)
2. Secondary to pneumomediastinum
 Supine AXR:
In massive pneumoperitoneum (usually in neonates), there
is a hyperlucent appearance of the whole abdomen,
falciform ligament is visualised, both sides of the walls of
the bowels (serosal and mucosal) are discretely seen
(Riglers sign)
On an upright view, the air collects beneath diaphragm.
The decubitus views may be helpful
 Free Intraperitoneal Air
Air on both sides of bowel wall
Crescent sign
Riglers Sign
 Free Intraperitoneal Air

Falciform Ligament Sign Football sign

Retroperitoneal Free Air
 IVC,AORTA, PANCREAS, ADRENAL, KIDNEYS

COLON ASCENDING, DESCENDING, DUODENUM 3rd.

 Retroperitoneal Free Air
Much less common than pneumoperitoneum.
Can be seen in perforation of the duodenum,
retrocaecal appendicitis or perforation of the
caecum
The diaphragmatic leaflet is clearly seen from
its origin and the inferior border of the heart is
also outlined
 Duodenal
perforation

Retroperitoneal air
outlining the inferior
diaphragm, psoas and
renal shadows
 Emphysematous

R Pyelonephritis
 Intramural air
Pneumatosis cystoides intestinalis is seen with loss
of mucosal integrity secondary to extensive
inflammatory disease or ischaemic disease of the
intestines
Infants and neonates : NEC, Hirschsprung disease
Older infants and children : collagen vascular
disease, steroid therapy, immunosuppressive
therapy, gastroenteritis and GIT obstruction
 Portal Vein Gas and Biliary Tract Gas
Portal vein gas is seen hand in hand with pneumatosis
cystoides intestinalis .The gas enters the portal
circulation from the intestinal wall, either through the
veins or the lymphatics and then to the liver
Biliary tract gas is seen with duodenal obstructions distal
to the entrance of the common bile duct. Normal if post
ERCP or CBD-jejunal anastomosis.
 Air in the portal vein,
Air in the bowel walls,
NEC Pneumoperitoneum
Pneumatosis [subdiaphragmatic free air, perihepatic
Portal vein gas free air, double wall sign (blue
arrows), triangle sign (green arrows),
and falciform ligament (red arrow)].
Portal vein gas
Mesenteric gas,
Pneumoperitoneum
Aerobilia
Aerobilia
3. CALCIFICATIONS
Abdominal Calcifications
Determine nature
Localisation may need lat/oblique
views
Pelvic vein phleboliths
Mesenteric lymph nodes
Vascular calcifications
Uterine fibroids
Benign or malignant ovarian masses
Adrenals
Abdominal Calcifications
.cont
Liver calcifications in hepatomas,
other tumours, hydatid cysts, old
abscesses, TB
Splenic calcifications in cysts,
infarcts, old haematomas, TB
Pancreatic calcifications in chronic
pancreatitis
Faecoliths in diverticula/ appendix
Soft tissue calcifications
Gall stones/ urinary/ costal cartilage
Abdominal Calcifications

Patterns
l Rimlike
l Linear or track-like
l Lamellar
l Cloudlike
Rimlike Calcification
l Wall of a hollow viscus
n Cysts
l Renal cyst
n Saccular organs e.g. GB
l Porcelain Gallbladder
Renal Cyst
Gallbladder Wall
Porcelain GB
Linear or Track-like

l Walls of a tube
n Ureters
n Arterial walls
Atherosclerosis
Abdominal aortic
calcification of
aneurysm
splenic vessels
 Distal ureteric stone oval, well
defined, no lucent centre. +Phleboliths

Bladder stone. +Phleboliths

Phleboliths round, well

defined, lucent centre
 Lamellar or Laminar

l Formed in lumen of a hollow viscus

n Renal stones
n Gallstones
n Bladder stones
 Staghorn calculi

Appendiculolith
Gall stones
Cloudlike, Amorphous, Popcorn

l Formed in a solid organ or tumor

n Liver, spleen , pancreas, kidneys
n Leiomyomas of uterus
n Ovarian cystadenomas
 Pelvic mass with fat and
Calcified uterine fibroid
tooth like calcification
Dermoid tumour
Chronic pancreatitis
Cortical Nephrocalcinosis Medullary Nephrocalcinosis
4. Soft Tissue Masses
 Soft Tissue Masses

l Hepatosplenomegaly
n Plain films poor for judging liver size
l Tumor or cyst
n Bowel displacement
l Paucity of gas
l Pad sign
n Extrinsic compression of bowel
Elderly man Hours
later

What was done at the hospital?

Bladder Outlet Obstruction

pre- and post- cathetherisation
Left renal cyst
R SUPINE
Liver abscess
QUIZ
Small bowel obstruction Large bowel obstruction
 Pneumoperitoneum
- football sign
R
AP
SUPINE
Appendiculolith Porcelain GB
Diaphragmatic herniaa
 Grossly distended stomach-
Congenital hypertrophic pyloric stenosis
Double gastric bubble Duodenal atresia
Intussuception
NORMAL AXR
Pneumoperitoneum Riglers sign
 Distal colonic obstruction

R AP SUPINE
R SUPINE R SUPINE

Pneumatosis intestinalis
Pneumoperitoneum
Subcutaneous emphysema.
Retroperitoneal air
The stomach is distended TENSION PNEUMOTHORAX
The liver displaced left inferior right lung collapse and
mediastinal shift.
Urethral Stone
WIRES
GLASS SHARDS
Can you identify the
objects?

1.Spoon (1) (broken)

2.Spoon (2)
3.Parker pen with metal body
4.Parker pen with metal body
5.Tweezers
6.Nail clippers
7.Nail file (metal with rubber
handle)
8.Pocket radio complete with
aerial and wrist strap
THANK YOU