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Radiology Abdomen Interpretations
Radiology Abdomen Interpretations
INTRODUCTION
PATTERN RECOGNITION
INTERPRETATION
AXR vs KUB
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
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
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)
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
R
SUPINE
Paralytic ileus
CASE 1
R SUPINE R ERECT
SUPINE
R SUPINE
R
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
R SUPINE
High GI obstruction
R SUPINE
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
Appendiculolith
Gall stones
Cloudlike, Amorphous, Popcorn
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
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?