Introduction to Normal Abdominal Radiographic Abd i l R di hi Anatomy

Department of Radiology, p gy, Vancouver General Hospital

Dr. Savvas Nicolaou Director of ER/Trauma Radiology savvas.nicolaou@vch.ca

Objectives
Be able to identify the following structures on a normal abdominal radiograph: GI Tract
Stomach Small intestine S ll i t ti Large intestine Liver Spleen

GU System Kidneys Bladder

Bones
Sacroiliac joint, Symphysis Pubis, Iliac crest, Femoral heads , Hip Joint Vertebral bodies Pedicles, Transverse process, spinous process

Muscles
Psoas major j

Be able to identify which abdominal organs are intraperitoneal and retroperitoneal

Anatomy R i A Review

Anatomical Planes

Sagittal

Coronal

Axial/Transverse

Basic Abdominal Anatomy

Abdomen extends from inferior margin of g thorax to the superior margin of pelvis and lower limb Peritoneum lines the abdominal cavity Forms the mesenteries that suspends viscera d i

Basic Abdominal Anatomy

BOWEL

Basic Radiographic Terminology

Attenuation describes the absorption of X-rays as they p y y traverse structures

Lucency = low attenuation appear black

e.g., air

O Opacity = hi h attenuation i high i appear white

e.g., bone eg

Abdomen

Radiography

5 major densities are found on radiographs, and are demonstrated on this image g

Soft Tissue Fat

Air - fat - water - bone - metal

Bone eta Metal Air

Lower

Attenuation

Higher

Note that THICK structures attenuate more radiation than THIN structures of the same composition

Patient Positioning

Supine

Erect

GASTROINTESTINAL SYSTEM Interpreting the Abdominal Radiograph How the radiograph is taken
Routine 3 Views: Supine AP abdomen Erect AP abdomen Erect chest x-ray

GASTROINTESTINAL SYSTEM Interpreting the Abdominal Radiograph How the radiograph is taken
Routine 3 Views: Supine AP abdomen Most useful for detecting bowel gas patterns Eg. dilated bowels, intraabdominal f fluid

GASTROINTESTINAL SYSTEM Interpreting the Abdominal Radiograph How the radiograph is taken
Routine 3 Views: Erect AP abdomen Most useful for detecting free air, air-fluid levels and bowel gas patterns Eg. Bowel obstruction

GASTROINTESTINAL SYSTEM Interpreting the Abdominal Radiograph How the radiograph is taken
Routine 3 Views: Erect chest x-ray Most useful in detecting intraperitoneal air (air under the diaphragm) May demonstrate thoracic disease causing abdominal pain

Normal gastric air bubble with air fluid level

Normal gastric air bubble with air fluid level

Air Under the Diaphragm Pathology

APPROACH TO EVALUATING A PLAIN ABDOMINAL FILM

3 SYSTEMS SYSTEMS:

SOFT TISSUES ABDOMINAL VISCERA

BOWEL GAS PATTERN

BONES- SKELETAL ELEMENTS

Liver

Spleen Stomach

pedicle
Hepatic flexure

Left kidney

Spinous process S i

Left psoas margin

Left sacroiliac joint

Left hip j p joint

Symphisis pubis

Soft Tissue
Liver Spleen Stomach y Left kidney Hepatic flexure

Left psoas margin

Rectum

ENLARGED SPLEEN

Bone

Spinous process

Pedicle ed c e Right iliac crest

Right acetabulum

Left sacroiliac joint

Right femoral head

Bowel Gas

Bowel Gas

GAS PATTERN Air Inside the Bowel Lumen

Property Location Central

Small Bowel

Large Bowel Peripheral (Picture Frame) Haustra , sacculations Interrupted: folds do not cross entire width 9cm at cecum, 10cm or more abnormal Max 6cm transverse colon if more than 6 abnormal 5mm Commonly contains solid fecal material

Circular Folds Mucosal Folds Uninterrupted folds cross entire width (Valvulae Conniventes)

Maximum diameter

3cm

Maximum fold 3mm thickness Rarely contains solid fecal material Fecal Content

LARGE BOWEL

SMALL BOWEL

Small vs. Large Intestine

Small Intestine

Large Intestine

Uninterrupted valvulae conniventes

Interrupted haustra

Valvulae conniventes small bowel mucosal folds

Multiple dilated loops of small bowel indicating a small bowel obstruction

Valvulae conniventes i t small bowel mucosal folds

small bowel obstruction indicating the presence of numerous small bowel air fluid levels

Small bowel mucosal folds circumferential valvulae conniventes (plicae semicircularis)

Large bowel folds - haustra

Spleen Stomach Left kidney Spinous process Pedicle P di l Left psoas margin Left sacroiliac joint Rectum

Liver

Hepatic flexure

Right iliac crest

Right g acetabulum

Right femoral head

Radiograph vs. 3D Reconstruction

3D Reconstruction

1 3 4 7 4

2 3

1. 2. 3. 4. 5. 6. 7. 8.

Liver Spleen Kidneys Psoas muscle Sacrum Rectum Vertebral Body Femoral Head

5 8 6 8

Radiograph Superimposition on 3D Reconstruction

1 3 4 7 4

2 3

1. 2. 3. 4. 5. 6. 7. 8. 8

Liver Spleen Kidneys Psoas muscle Sacrum Rectum Vertebral Body Femoral Head

5 8 6 8

Radiograph Superimposition on 3D Reconstruction

1 3 4 7 9 5 8 6 4

2 3

1. 2. 3. 4. 5. 6. 7. 8. 8 9.

Liver Spleen Kidneys Psoas muscle Sacrum Rectum Vertebral Body Femoral Head Ilium

Radiograph Superimposition on 3D Reconstruction

1 3

2 3

4 7

9 5 8 6

1. 2. 3. 4. 5. 6. 7. 8. 8 9.

Liver Spleen Left kidney Psoas muscle Sacrum Rectum Vertebral Body Femoral Head Ilium

Radiograph vs. 3D Reconstruction

Radiograph vs. 3D Reconstruction

3D Reconstruction

1 2 3 4 5 5

1. 1 2. 3. 4. 5.

Kidneys Vertebral Body Ilium Sacrum Femoral Head

Radiograph vs. 3D Reconstruction

1 2

1. 1 2. 3. 4. 5.

Kidneys Vertebral Body Ilium Sacrum Femoral Head

3 4 5

Radiograph vs. 3D Reconstruction

1 2

1. 1 2. 3. 4. 5.

Kidneys Vertebral Body Ilium Sacrum Femoral Head

3 4 5

Radiograph vs. 3D Reconstruction

1 3

2 3

4 7

9 5

1. 2. 3. 4. 5. 6. 7. 8. 9.

Liver Spleen Left kidney Psoas muscle Sacrum Rectum Vertebral Body Femoral Head Ilium

Coronal view

3 1 2 4 7 4 6 6 5 3 4

1. 2. 2 3. 4.

Liver Gallbladder Stomach Small intestine

5. Descending colon 6. 6 Rectum 7. Ascending colon

Coronal view

3 1 3

2 2

1. Stomach 1 St h 2. Psoas muscles 3. Spleen

Coronal view
1 3 4 2

1 4

2 3

7
6

7 6

1. 2. 2 3. 4.

Liver Spleen Left kidney Psoas muscle

5. Gluteal muscles 6. 6 Rectum 7. Sacrum

Coronal view
1 3 2

2 3

4 4 5 5 6
1. 1 Liver 2. Spleen 3. Left kidney 4. 4 Vertebral Body 5. Illium 6. Femoral Head

FINAL REVIEW OF PLAIN XRAY ANATOMY

Liver

Spleen Stomach

pedicle
Hepatic flexure

Left kidney

Spinous process S i

Left psoas margin

Left sacroiliac joint

Left hip j p joint

Symphisis pubis