016 167 Plain X-Ray Abdomen

Key Contents

Key concepts of abdominal x-ray.Steps of preparation for abdominal x-ray.

Interpretation of abdominal x-ray.Abdominal x-ray and trauma.

Abdominal x-ray and intestinal obstruction.

Learning Objectives

To explain preparation and indication of abdominal x-ray.To interpret abdominal x-ray in trauma.

To relate abdominal x-ray with intestinal pathology.To understand limitation of abdominal x-ray.

Article Citation: Tahir S, Plain X-ray Abdomen, Indep Rev Jan-Mar 2012;14(1-3):136-144

Correspondence Address:

Dr. M. Shuja TahirProfessor of SurgeryIndependent Medical College & Hospital Faisalabad.

[email protected]

Independent Review Vol:14: No:1 (136-144) 136www.indepreviews.com

Plain X-Ray Abdomen

Indep Rev Jan-Mar 2012;14(1-3) IR-167

M. Shuja Tahir

Key words: Abdominal X-ray, Psoas Shadow, Sentinel Loops, Volvulus, Air fluid levels.


Anatomy of Thyroid Gland 7


Plain X-ray Abdomen 2

It is the radiological examination of abdomen relatively poor alternate and does not provide and its contents. enough information. The areas of lower chest

and pelvis are also exposed to have complete It is used as a screening investigation in visualization of the abdomen.various abdominal problems such as; The clinical data is always critically examined

before performing the radiological ! Gastro-intestinal problems investigations. It is inspected and interpreted ! Inflammations of abdominal viscera in an organized and structured manner.! Abdominal trauma! Urinary tract problems! Gynaecological problems.! Vascular problems Whole of the exposed film is seen over an ! Retroperitoneal problems. illuminater and never against sunlight or

electric light to avoid wrong conclusions. Possible provisional diagnosis is made and objective interpretation is done.

The plain film is exposed with or without preparation. The abdominal x-ray is exposed in appropriate position. The x-ray pictures are Large amount of gas is seen in stomach and exposed in erect or standing position and colon. Stomach is identified because of its supine or lying position. Occasionally the films anatomical position and contents. An air-fluid are exposed in lateral position as well. level is seen under the left hemidiaphragm

normally. The presence of gas in the bowel is Sometimes the patient is unfit to stand, then seen on plain film. lateral decubitus film is exposed. It is a

OVER VIEW

Plain x-ray abdomen (normal film) after preparation

Plain x-ray abdomen (normal film) without preparation





Gas is normally present in the stomach, small and large intestine in small quantities. The gas is present as individual bubbles of gas scattered in the bowel.

lines on both sides of spine starting from first lumbar vertebra towards pelvis.

The psoas shadows may be obliterated by inflammatory, neoplastic and hemorrhagic

Peritoneal and extra-peritoneal contents of (traumatic) lesions of the organ in front and in abdomen and pelvis are examined. Pancreas the vicinity (pancreas, spleen, liver etc.)cannot be seen on plain film of abdomen.

Ascities or presence of pus in the peritoneal If a loop of bowel is seen filled with gas, it cavity is identified by typical ground glass should not be longer than 5-8 cm and should appearance. It offers valuable diagnostic not be distended under normal circumstances. information. The gas does not form a loop pattern in healthy persons. Radio-opaque shadows and calcifications in

the film are seen and their anatomical Gas shadows outside the intestine always correlation is interpreted.indicate intra-abdominal pathology.

Soft tissue shadows of liver, spleen, kidneys, Multiple gas-fluid levels in the dilated loops of and psoas muscle are visible normaly. Outline small or large gut indicate obstruction to the of urinary bladder, if filled with urine may be gastrointestinal flow. The level of obstruction seen on plain film.is usually looked for.

The plain x-ray film of the abdomen showing The psoas shadows are visible as diverging complete urinary system is called KUB film

Plain x-ray abdomen showing diverging psoas shadows

Plain x-ray abdomen (normal) KUB film





(Kidney, Ureter, Bladder film). The free air may be either due to perforation of the hollow viscus or the air entering from the exterior.

The injuries of abdomen show various The free gas appears about 1-2 hours after the radiological features depending upon the perforation of bowel.type, time and site of injury.

The common features seen on plain x-ray abdomen after various type of trauma are:! Pneumoperitoneum! Ground glass appearance! Psoas shadow obliteration! Sentinel loops

Trauma may be;! Penetrating! Blunt

The penetrating injuries are usually visible on clinical examination. But the extent of injury may not be evaluated specifically on clinical Absence of free gas in the peritoneal cavity examination. It presents with pneumoperi- does not necessarily exclude presence of toneum on radiological examination in the perforation as it is absent in approximately earlier part. 25% cases of perforated duodenal ulcer. It is

very rare in acute appendicitis even if it is Similarly blunt injuries of abdomen are perforated. It is seen in following conditions;diagnosed from clinical history and

! Perforated duodenal ulcerexamination but extent of injury can only be

! Perforated gastric ulcerassessed by various investigations and

! Perforated gastric carcinomasometimes even laparoscopy or laparotomy

! Perforated colonic carcinomamay be required.

! Perforated colonic diverticulum ! Traumatic gastric rupture! Traumatic small gut rupture

Normally no air is present in peritoneal cavity. ! Traumatic colonic rupture

Pneumoperitoneum is the presence of free air ! Typhoid perforation

in the peritoneal cavity. The most common ! Diagnostic pneumoperitoneum

site is usually under the right dome of ! Post laparotomy pneumoperitoneum

diaphragm.! Post laparoscopy pneumoperitoneum.! Penetrating intraperitoneal injuries

The penetrating injuries of abdomen present ! Diagnostic fallopian tube insufflation

with free air in the peritoneal cavity. ! Gas gangrene of intra peritoneal

(Pneumoperitoneum) viscera.

ABDOMINAL TRAUMA

PNEUMOPERITONEUM

X-ray chest showing air under the diaphragm (pneumoperitoneum)





! Septic peritonitis with gas forming traumatic or inflammatory lesions. The local organisms. distention of intestinal loop is due to local

paralysis and accumulation of gas in the intestinal loop.

This is a typical feature seen on x-ray In acute pancreatitis, the sentinel loop is abdomen. It is visible due to presence of fluid, usually seen in left hypochondrium while in pus or blood in the peritoneal cavity. The acute appendicitis, the sentinel loop is seen in presence of fluid gives this appearance on right iliac fossa. The sentinel loop is seen in plain x-ray abdomen. This is seen within few right hypochondrium in acute cholecystitis. hours after penetrating injuries of abdomen

when the peritonitis has already set in.Other radiological features of peritonitis are also seen in late cases of blunt injuries of abdomen, when peritonitis has developed ( G r o u n d g l a s s a p p e a r a n c e a n d pneumoperitoneum).

There are many inflammatory lesions of peritoneal viscera. The history of illness is present for some period. The acute symptoms of intestinal perforation and resulting peritonitis are seen as pneumoperitoneum, ground glass appearance and Psoas shadow obliteration.

The blunt injury of abdomen may lead to injury to the hollow viscera leading to leakage of The duodenal ulcer and gastric ulcer gastro-intestinal contents into the peritoneal perforations used to be one of the most cavity and similar radiological features. common surgical emergencies during

previous decades. Now in our Indo-Pak subcontinent the incidence of typhoid

The hematomas are formed which may perforation is higher.obliterate the psoas shadow in case of injury to the solid organs. This feature is seen in These conditions can be diagnosed reasonably hepatic, splenic and renal trauma. It is also well by looking at the plain x-ray of the seen in pancreatic injuries or infections. abdomen. It shows free gas under the

diaphragm specially on right side in most of the cases. Ileal perforation due to typhoid

An isolated distended loop of bowel is seen presents in this manner.near the site of injured viscus or inflamed organ. This loop is called a "sentinel loop". It is Perforations of other intra peritoneal hollow a feature due to body's efforts to localize viscera also present similarly. Perforation of

GROUND GLASS APPEARANCE

INFLAMMATORY & MISCELLANEOUS LESIONS OF ABDOMEN

PSOAS SHADOW OBLITERATION

SENTINEL LOOPS

Plain x-ray abdomen showing ground glass appearance due to presence of fluid or pus in the peritoneal cavity





distension of intestinal loops and gas fluid levels inside the intestine.

appendix is rarely associated with pneumoperitoneum. The gas shadows are better seen in supine or

lying position film. More than two fluid levels seen in small gut are abnormal and

The obstruction to the flow of contents of pathological.gastrointestinal tract can be;

The gas filled loops of gut show increase in their diameter due to distension.

! Acute! Subacute The fluid levels are seen in erect or standing ! Chronic films or lateral decubitus films.

! Adynamic ileus The small gut distended loops are recognized The causes of intestinal obstruction may be by the following features;external or internal hernias, adhesions,

! The caecum is not distended in cases neoplasia, volvulous, stenotic lesions, of small intestinal obstruction.inflammatory lesions, meconeum and

! The location of distended loops or air gallstones. fluid level is central.

! Fine serrations along the margins After 3-5 hours of acute intestinal obstruction, formed by mucosal folds are complete enough gas and fluid accumulates to show

INTESTINAL OBSTRUCTION

MECHANICAL

PARALYTIC SMALL INTESTINAL OBSTRUCTION

Plain x-ray abdomen (supine film) showing dilated jejunal loops due to small gut obstruction

Plain x-ray abdomen (erect film) showing multiple air fluid levels in the loops of jejunum due to small gut obstruction.





! The distended colonic loops are along the transverse axis in case of

present at the periphery in the jejunum.

abdomen.! These fine serrations are very close to

! The gas fluid levels are seen and these each other.

are more than those normally seen in a ! Featureless gut (with serrations) is

single x-ray view.seen in ileal obstruction.

! The serrations are partial and ! 6 Step ladder pattern of air fluid

incomple te . These look l i ke shadows is also seen some times.

indentations into the transverse diameter of the colon. These are not opposite each other but are

The colon is distended from caecum to the alternating.obstructive lesion where the distension ends abruptly.

In cases of volvulus of sigmoid colon, an Haustrations are deeper and these are not

inverted U shaped distended loop of colon is continuous along the transverse axis of colon.

seen in the pelvis and abdomen. Double fluid These are in fact alternating type.

levels may be seen.

If caecum gets distended more than 9-10 cm In cases of peritonitis, the signs of free fluid

it is likely to perforate.present in the peritoneal cavity, sentinel loop or a localized distended loop of bowel is seen

Colonic obstruction presents with following adjacent to the lesion.

features on x-ray abdomen;! The caecum and colon are distended.

COLONIC OBSTRUCTION

VOLVULUS OF COLON

Plain x-ray abdomen showing marked dilatation of the large gut from caecum to splenic flexure due to large gut obstruction.

Plain x-ray abdomen showing dilatation of large gut due to twisted and obstructed caecum and ascending colon due to volvulus of caecum





COLONIC CARCINOMA GALL STONE ILEUS

ACUTE MESENTERIC OCCLUSION

Most often these are not diagnosed from In cases of gall stone ileus when the gall stone presence of soft tissue shadows. When these has ulcerated into the duodenum and lesions are causing partial or complete descended along the small intestine, it causes obstruction or perforation, these can be small gut obstruction. It presents with detected indirectly from; following features;

! All the features of small intestinal ! Radiological features of intestinal obstruction are present.

obstruction ! It is diagnosed by presence of stone ! Features of intestinal perforation which is usually radio-opaque.! Features of generalized peritonitis ! Gas shadow is seen in the biliary tree

(common bile duct, common hepatic duct and hepatic ducts).

! The gall bladder may also be filled by It shows the features of peritonitis and may be the gas.detected by plain x-ray abdomen.

Gas shadow is seen in biliary tree in following conditions;These can not be seen on plain x-ray film ! Colo-biliary fistula due to gall stone directly. Various features such as presence of

erosion.sentinel loops, abnormal diaphragmatic ! Duodeno-biliary fistula due to gall shadows and ground glass appearance may

stone erosion or duodenal ulcer help in suspecting the lesion.penetration.

! Sphinterotomy or sphinteroplasty of Presence of air fluid level under the diaphragm sphinter of oddi.is highly suspicious of subphrenic collection.

! Choledocho-duodenal anastomosis.Ultrasound examination helps to confirm the ! Acute cholecystitis with gas forming diagnosis.

organisms.

INTRA ABDOMINAL ABSCESSES

Plain x-ray abdomen showing air fluid level under the right dome of diaphragm due to presence of gas in the right subphrenic abscess

Plain x-ray abdomen showing gas in the biliary passages and gall bladder due to gall stone ileus





GYNECOLOGICAL PROBLEMS FIBROID UTERUS

OVARIAN TUMOURS

RENAL TUMOURS

FOREIGN BODIES

CYSTS

In women, uterine shadow may also be seen specially if the patient is not fat or the fibroid is calcified. It is easily seen on plain film x-ray of the pelvic area.

Normally these are not picked up on plain film at an early stage. Teratomas may be detected because of radiopaque structures present in these tumours (cartilage, teeth etc)

Soft tissue renal shadow is usually seen in properly prepared patients and occasionally renal lesion may be detected on plain x-ray abdomen.

Stones in the gall bladder and stones in the urinary system are seen as radio-opaque shadows in the relevant area.

These cases are diagnosed if the stones are radio-opaque otherwise ultrasonography, cholecysto-graphy or urography is required.

Foreign bodies may be ingested accidently. These usually pass through the gastro intestinal tract easily if small and not pointed. Even needles may pass without causing perforation.Soft tissue shadows of larger cysts may

occasionally be out lined on plain film. But The plain x-ray of abdomen helps in finding most often these are undetected and require the site and type of foreign body if it is radio-ultrasound examination or urography for opaque. If the foreign body is obstructed at proper detection.some place, it may be removed surgically.

CALCULUS DISEASE

Plain x-ray abdomen (normal film) after preparation

Plain x-ray abdomen showing multiple radio-opeque shadows inthe upper part (multiple biliary and bilateral renal stones)

REFERENCES Blackwell Scientific publications London. pp 133-143, 19981. Peter Armstrong. Martin L. Wastie. Plain

Abdomen: In Diagnostic Imaging. 4th Edition



016 167 Plain X-Ray Abdomen

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