PLAIN X-RAY ABDOMEN 63

PLAIN X-RAY ABDOMEN INV-08

Shuja Tahir, FRCSEd

It is the radiological examination of abdomen and The plain film is exposed with or without
its contents. preparation. The abdominal x-ray is exposed in
appropriate position. The x-ray pictures are
It is used as a screening investigation in various exposed in erect or standing position and supine
abdominal problems such as; or lying position. Occasionally the films are
exposed in lateral position as well.
1. Gastro-intestinal problems
2. Inflammations of abdominal viscera Sometimes the patient is unfit to stand, then
3. Abdominal trauma lateral decubitus film is exposed. It is a relatively
4. Urinary tract problems poor alternate and does not provide enough
5. Gynaecological problems. information. The areas of lower chest and pelvis
6. Vascular problems are also exposed to have complete visualization
7. Retroperitoneal problems. of the abdomen.

Plain x-ray abdomen (normal film) without preparation

Plain x-ray abdomen (normal film) after preparation

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The clinical data is always critically examined
before performing the radiological investigations.
It is inspected and interpreted in an organized and
structured manner.
OVER VIEW
Whole of the exposed film is seen over an
illuminater and never against sunlight or electric
light to avoid wrong conclusions. Possible
provisional diagnosis is made and objective
interpretation is done.
Large amount of gas is seen in stomach and
colon. Stomach is identified because of its
anatomical position and contents. An air-fluid level
is seen under the left hemidiaphragm normally.
The presence of gas in the bowel is seen on plain
film.
Plain x-ray abdomen showing diverging psoas shadows
Gas is normally present in the stomach, small and
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PLAIN X-RAY ABDOMEN
large intestine in small quantities. The gas is
present as individual bubbles of gas scattered in
the bowel.
Peritoneal and extra-peritoneal contents of
abdomen and pelvis are examined. Pancreas
cannot be seen on plain film of abdomen.
If a loop of bowel is seen filled with gas, it should
not be longer than 5-8 cm and should not be
distended under normal circumstances. The gas
does not form a loop pattern in healthy persons.
Gas shadows outside the intestine always
indicate intra-abdominal pathology.
Plain x-ray abdomen (normal) KUB film
Multiple gas-fluid levels in the dilated loops of
small or large gut indicate obstruction to the
gastrointestinal flow. The level of obstruction is
PLAIN X-RAY ABDOMEN 65

usually looked for. 3. Psoas shadow obliteration

The psoas shadows are visible as diverging lines
on both sides of spine starting from first lumbar
vertebra towards pelvis.
The psoas shadows may be obliterated by
inflammatory, neoplastic and hemorrhagic
(traumatic) lesions of the organ in front and in the
vicinity (pancreas, spleen, liver etc.)
Ascities or presence of pus in the peritoneal cavity
is identified by typical ground glass appearance.
It offers valuable diagnostic information.
Radio-opaque shadows and calcifications in the
film are seen and their anatomical correlation is
interpreted.
Soft tissue shadows of liver, spleen, kidneys, and
psoas muscle are visible normaly. Outline of
urinary bladder, if filled with urine may be seen
on plain film.
4. Sentinel loops
Trauma may be;
a. Penetrating
b. Blunt
The penetrating injuries are usually visible on
clinical examination. But the extent of injury may
not be evaluated specifically on clinical
examination. It presents with pneumoperitoneum
on radiological examination in the earlier part.
Similarly blunt injuries of abdomen are diagnosed
from clinical history and examination but extent
of injury can only be assessed by various
investigations and sometimes even laparoscopy
or laparotomy may be required.
PNEUMOPERITONEUM
Normally no air is present in peritoneal cavity.

The plain x-ray film of the abdomen showing

complete urinary system is called KUB film
(Kidney, Ureter, Bladder film).

ABDOMINAL TRAUMA

The injuries of abdomen show various radiological

features depending upon the type, time and site
of injury.

The common features seen on plain x-ray

abdomen after various type of trauma are:

1. Pneumoperitoneum
X-ray chest showing air under the diaphragm
2. Ground glass appearance (pneumoperitoneum)

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66 PLAIN X-RAY ABDOMEN

Pneumoperitoneum is the presence of free air in GROUND GLASS APPEARANCE

the peritoneal cavity. The most common site is
usually under the right dome of diaphragm.
The penetrating injuries of abdomen present with
free air in the peritoneal cavity.
(Pneumoperitoneum)
The free air may be either due to perforation of
the hollow viscus or the air entering from the
exterior.
The free gas appears about 1-2 hours after the
perforation of bowel.
This is a typical feature seen on x-ray abdomen.
It is visible due to presence of fluid, pus or blood
in the peritoneal cavity. The presence of fluid
gives this appearance on plain x-ray abdomen.
This is seen within few hours after penetrating
injuries of abdomen when the peritonitis has
already set in.
The blunt injury of abdomen may lead to injury to
the hollow viscera leading to leakage of gastro-
intestinal contents into the peritoneal cavity and
similar radiological features.

Absence of free gas in the peritoneal cavity does

not necessarily exclude presence of perforation
as it is absent in approximately 25 % cases of
perforated duodenal ulcer. It is very rare in acute
appendicitis even if it is perforated. It is seen in
following conditions;

1. Perforated duodenal ulcer

2. Perforated gastric ulcer
3. Perforated gastric carcinoma
4. Perforated colonic carcinoma
5. Perforated colonic diverticulum
6. Traumatic gastric rupture
7. Traumatic small gut rupture
8. Traumatic colonic rupture
9. Typhoid perforation
10. Diagnostic pneumoperitoneum
11. Post laparotomy pneumoperitoneum
12. Post laparoscopy pneumoperitoneum.
Plain x-ray abdomen showing ground glass
13. Penetrating intraperitoneal injuries appearance due to presence of fluid or pus in
14. Diagnostic fallopian tube insufflation the peritoneal cavity
15. Gas gangrene of intra peritoneal viscera. PSOAS SHADOW OBLITERATION
16. Septic peritonitis with gas forming organisms
The hematomas are formed which may obliterate

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PLAIN X-RAY ABDOMEN 67

the psoas shadow in case of injury to the solid Indo-Pak subcontinent the incidence of typhoid
organs. This feature is seen in hepatic, splenic perforation is higher.
and renal trauma. It is also seen in pancreatic
injuries or infections. These conditions can be diagnosed reasonably
well by looking at the plain x-ray of the abdomen.
SENTINEL LOOPS It shows free gas under the diaphragm specially
on right side in most of the cases. Ileal perforation
An isolated distended loop of bowel is seen near due to typhoid presents in this manner.
the site of injured viscus or inflamed organ. This
loop is called a "sentinel loop". It is a feature due
to body's efforts to localize traumatic or
inflammatory lesions. The local distention of
intestinal loop is due to local paralysis and
accumulation of gas in the intestinal loop.

In acute pancreatitis, the sentinel loop is usually

seen in left hypochondrium while in acute
appendicitis, the sentinel loop is seen in right iliac
fossa. The sentinel loop is seen in right
hypochondrium in acute cholecystitis.

Other radiological features of peritonitis are also

seen in late cases of blunt injuries of abdomen,
when peritonitis has developed (Ground glass
appearance and pneumoperitoneum).

INFLAMMATORY & MISCELLANEOUS

LESIONS OF ABDOMEN

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 duodenal ulcer and gastric ulcer perforations
used to be one of the most common surgical
emergencies during previous decades. Now in our
Plain x-ray abdomen (supine film) showing
dilated jejunal loops due to small gut
obstruction
Perforations of other intra peritoneal hollow
viscera also present similarly. Perforation of
appendix is rarely associated with
pneumoperitoneum.
INTESTINAL OBSTRUCTION
The obstruction to the flow of contents of

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gastrointestinal tract can be;
MECHANICAL
C Acute
C Subacute
C Chronic
PARALYTIC
C Adynamic ileus
Plain x-ray abdomen (erect film) showing
multiple air fluid levels in the loops of jejunum
due to small gut obstruction.
The causes of intestinal obstruction may be
external or internal hernias, adhesions, neoplasia,
volvulous, stenotic lesions, inflammatory lesions,
meconeum and gallstones.
After 3-5 hours of acute intestinal obstruction,
enough gas and fluid accumulates to show
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PLAIN X-RAY ABDOMEN
distension of intestinal loops and gas fluid levels
inside the intestine.
The gas shadows are better seen in supine or
lying position film. More than two fluid levels seen
in small gut are abnormal and pathological.
The gas filled loops of gut show increase in their
diameter due to distension.
The fluid levels are seen in erect or standing films
or lateral decubitus films.
SMALL INTESTINAL OBSTRUCTION
The small gut distended loops are recognized by
the following features;
1. The caecum is not distended in cases of
small intestinal obstruction.
2. The location of distended loops or air fluid
level is central.
3. Fine serrations along the margins formed by
mucosal folds are complete along the
transverse axis in case of jejunum.
4. These fine serrations are very close to each
other.
5 Featureless gut (with serrations) is seen in
ileal obstruction.
6 Step ladder pattern of air fluid shadows is
also seen some times.
COLONIC OBSTRUCTION
The colon is distended from caecum to the
obstructive lesion where the distension ends
abruptly.
Haustrations are deeper and these are not
PLAIN X-RAY ABDOMEN
continuous along the transverse axis of colon.
These are in fact alternating type.
If caecum gets distended more than 9-10 cm it is
likely to perforate.
Colonic obstruction presents with following
features on x-ray abdomen;
1. The caecum and colon are distended
2. The distended colonic loops are present at
the periphery in the abdomen.
Plain x-ray abdomen showing marked dilatation
of the large gut from caecum to splenic flexure
due to large gut obstruction.
3. The gas fluid levels are seen and these are
more than those normally seen in a single
x-ray view.
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69
4. The serrations are partial and incomplete.
These look like indentations into the
transverse diameter of the colon. These are
not opposite each other but are alternating.
VOLVULUS OF COLON
In cases of volvulus of sigmoid colon, an inverted
U shaped distended loop of colon is seen in the
pelvis and abdomen. Double fluid levels may be
seen.
Plain x-ray abdomen showing dilatation of
large gut due to twisted and obstructed
caecum and ascending colon due to volvulus
of caecum
In cases of peritonitis, the signs of free fluid
present in the peritoneal cavity, sentinel loop or
a localized distended loop of bowel is seen
adjacent to the lesion.
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COLONIC CARCINOMA
Most often these are not diagnosed from presence
of soft tissue shadows. When these lesions are
causing partial or complete obstruction or
perforation, these can be detected indirectly from;
1. Radiological features of intestinal obstruction
2. features of intestinal perforation
3. features of generalized peritonitis
ACUTE MESENTERIC OCCLUSION
It shows the features of peritonitis and may be
detected by plain x-ray abdomen.
INTRA ABDOMINAL ABSCESSES
These can not be seen on plain x-ray film directly.
Plain x-ray abdomen showing air fluid level
under the right dome of diaphragm due to
presence of gas in the right subphrenic
abscess
Various features such as presence of sentinel
loops, abnormal diaphragmatic shadows and
ground glass appearance may help in suspecting
the lesion.
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PLAIN X-RAY ABDOMEN
Presence of air fluid level under the diaphragm
is highly suspicious of subphrenic collection.
Ultrasound examination helps to confirm the
diagnosis.
GALL STONE ILEUS
In cases of gall stone ileus when the gall stone
has ulcerated into the duodenum and descended
along the small intestine, it causes small gut
obstruction. It presents with following features;
1. All the features of small intestinal obstruction
are present.
2. It is diagnosed by presence of stone which
is usually radio-opaque.
3. Gas shadow is seen in the biliary tree
(common bile duct, common hepatic duct and
hepatic ducts).
Plain x-ray abdomen showing gas in the biliary
passages and gall bladder due to gall stone
ileus
PLAIN X-RAY ABDOMEN 71

4. The gall bladder may also be filled by the gas.

Gas shadow is seen in biliary tree in following

conditions;

1. Colo-biliary fistula due to gall stone erosion.

2. Duodeno-biliary fistula due to gall stone

erosion or duodenal ulcer penetration.

3. Sphinterotomy or sphinteroplasty of sphinter

of oddi
Plain x-ray abdomen showing calcification in
the large uterine fibroid
4. Choledocho-duodenal anastomosis
CYSTS
5. Acute cholecystitis with gas forming
organisms. Soft tissue shadows of larger cysts may

GYNECOLOGICAL PROBLEMS
FIBROID UTERUS

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.

OVARIAN TUMOURS

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)

RENAL TUMOURS

Soft tissue renal shadow is usually seen in

properly prepared patients and occasionally renal
lesion may be detected on plain x-ray abdomen. Plain x-ray abdomen showing multiple radio-
opaque shadows in the upper part (multiple
biliary and bilateral renal stones)

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occasionally be out lined on plain film. But most
often these are undetected and require ultrasound
examination or urography for proper detection.
CALCULUS DISEASE
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,
cholecystography or urography is required.
FOREIGN BODIES
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PLAIN X-RAY ABDOMEN
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.
The plain x-ray of abdomen helps in finding the
site and type of foreign body if it is radio-opaque.
If the foreign body is obstructed at some place,
it may be removed surgically.
REFERENCES
1. Peter Armstrong. Martin L. Wastie. Plain
Abdomen: In Diagnostic Imaging. 4th Edition
Blackwell Scientific publications London. pp
133-143, 1998
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