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Plain Films

Of the AbdomenAn Approach

In Slide Show mode, to advance slides, press spacebar

William Herring, M.D. 2002

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What to Examine

Gas pattern

Extraluminal air

Soft tissue masses

Calcifications

GESC

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Normal Gas Pattern

Stomach

Always Small Bowel

Two or three loops of non-distended bowel

Normal diameter = 2.5 cm = 1 US quarter

Large Bowel

In rectum or sigmoid almost always

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Gas in

stomach

Gas in a few

loops of

small bowel

Gas in

rectum or

sigmoid

Normal Gas Pattern

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Normal Fluid Levels

Stomach

Always (except supine film)

Small Bowel

Two or three levels possible

Large Bowel

None normally

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Erect Abdomen

Always

air/fluid level

in stomach

A fewair/fluid

levels in

small bowel

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Large vs. Small Bowel

Large Bowel

Peripheral

Haustral markings don't extend

from wall to wall

Small Bowel

Central Valvulae extend across lumen

Maximum diameter of 2"

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Complete AbdomenObstruction Series

Supine Prone or lateral rectum

Erect or left decubitus

Chest - erect or supine

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Complete AbdomenSupine

Looking for

Scout film for gaspattern

Calcifications

Soft tissue masses

Substitute none

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Complete AbdomenProne

Looking for

Gas in rectum/sigmoid

Gas in ascending and

descending colon

Substitute lateral

rectum

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Complete AbdomenErect

Looking for

Free air

Air-fluid levels

Substitute left

lateral decubitus

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Complete AbdomenErect Chest

Looking for

Free air

Pneumonia at bases

Pleural effusions

Substitute supine

chest

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Abnormal Gas Patterns

Functional Ileus

Localized (Sentinel Loops)

Generalized adynamic ileus

Mechanical Obstruction

SBO

LBO

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Air in Rectumor sigmoid

Air in SmallBowel

Air in LargeBowel

LocalizedIleus

Yes2-3 distended

loopsAir in rectum or

sigmoid

GeneralizedIleus

YesMultiple

distended loopsYes-

Distended

SBO NoMultiple dilated

loopsNo

LBO NoNone-unless

ileocecal valveincompetent

Yes-Dilated

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One or two persistently dilated loops of

large or small bowel

Gas in rectum or sigmoid

Localized IleusKey Features

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Sentinel Loops

Supine Prone

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PancreatitisUlcer

Diverticulitis

Cholecystitis

Appendicitis

Ulcer

Ureteral calculus

Sentinel Loops

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Localized IleusPitfalls

May resemble earlymechanical SBO

Clinical course

Get follow-up

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Gas in dilated small bowel and largebowel to rectum

Long air-fluid levels

Only post-op patients havegeneralized ileus

Generalized IleusKey Features

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Generalized Adynamic Ileus

Supine Erect

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Is It An Ileus?

Is the patient immediately post-op?

Are the bowel sounds absent or

hypoactive?

If no, then it isnt an ileus

Patients dont present to the ER with a

generalized adynamic ileus!

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Mechanical SBOKey Features

Dilated small bowel

Fighting loops

Little gas in colon, especially rectum

Key: disproportionate dilatation of SB

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SBO

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Mechanical SBOCauses

Adhesions

Hernia*

Volvulus

Gallstone ileus*

Intussusception

*Cause may be visible on plain film

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Mechanical SBOPitfalls

Early SBO mayresemble

localized ileus -

get F/O

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Mechanical LBOKey Features

Dilated colon to point of obstruction

Little or no air in rectum/sigmoid

Little or no gas in small bowel, if

Ileocecal valve remains competent

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LBO

Supine Prone

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Mechanical LBOCauses

Tumor

Volvulus

Hernia

Diverticulitis

Intussusception

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Mechanical LBOPitfalls

Incompetent ileocecal valve Large bowel decompresses into small

bowel

May look like SBO

Get BE or follow-up

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Carcinoma of Sigmoid LBO

Decompressed into SB

ProneSupine

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Air in Rectumor sigmoid

Air in SmallBowel

Air in LargeBowel

LocalizedIleus

Yes2-3 distended

loopsAir in rectum or

sigmoid

GeneralizedIleus

YesMultiple

distended loopsYes-

Distended

SBO NoMultiple dilated

loopsNo

LBO NoNone-unless

ileocecal valveincompetent

Yes-Dilated

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Aunt Minnie Diagnoses

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Air in

biliary

treeSBO

Gallstone Gallstone Ileus

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Post-op C-section

Adynamic Ileus

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Sigmoid Volvulus

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Cecal Volvulus

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Mesenteric Occlusion

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Abnormal Gas PatternsIleus and Obstruction

Localized ileus Generalized ileus

Mechanical SBO

Mechanical LBO

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Extraluminal AirFree Intraperitoneal Air

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Signs of Free Air

Air beneath diaphragm

Both sides of bowel wall

Falciform ligament sign

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Crescent

sign

Free Intraperitoneal Air

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Free Intraperitoneal Air

Air on both sides of

bowel wallRiglers

Sign

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Free Intraperitoneal Air

Falciform

LigamentSign

Football sign

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Free AirCauses

Rupture of a hollow viscus

Perforated ulcer

Perforated diverticulitis

Perforated carcinoma

Trauma or instrumentation

Post-op 57 days

NOT perforated appendix

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Air in Lesser Sac

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Extraperitoneal Air

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Soft Tissue Masses

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Soft Tissue Masses

Hepatosplenomegaly

Plain films poor for judging liver size Tumor or cyst

Bowel displacement

Paucity of gas

Pad sign

Extrinsic compression of bowel

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Splenomegaly

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Myomatous Uterus

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Bladder Outlet Obstruction pre- and post- cath

Hours

later

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Mass in Cologastric Space - Pancreatic Pseudocyst

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Right Renal Cyst

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RLQ Abscess

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Free Peritoneal Fluid- Bladder Ears

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AbdominalCalcifications

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Abdominal CalcificationsPatterns

Rimlike Linear or track-like

Lamellar

Cloudlike

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Rimlike Calcification

Wall of a hollow viscus

Cysts

Renal cyst

Aneurysms

Aortic aneurysm

Saccular organs e.g. GB

Porcelain Gallbladder

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Renal Cyst Gallbladder Wall

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Linear or Track-like

Walls of a tube

Ureters

Arterial walls

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Atherosclerosis Calcification Vas Deferens

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Lamellar or Laminar

Formed in lumen of a hollow viscus Renal stones

Gallstones

Bladder stones

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Stone in Ureterocoele Staghorn Calculi

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Cloudlike, Amorphous, Popcorn

Formed in a solid organ or tumor Leiomyomas of uterus

Ovarian cystadenomas

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Nephrocalcinosis Myomatous Uterus

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What to Examine

Gas pattern

Extraluminal air

Soft tissue masses

Calcifications

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The End