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08-120

Comparative Study Of Plain Film Abdomen And Ultrasound

In Non-Traumatic Acute Abdomen
K GUPTA, RK BHANDARI, R CHANDER
ABSTRACT
The comparative study of plain x-ray film abdomen and ultrasound in non-traumatic acute abdomen was
done in 50 patients with acute abdominal pain seen in the Department of Radiodiagnosis and Imaging of
Govt. Medical College, Amritsar during the year 2000-2001. Ultrasound was highly accurate in diagnosing
the exact cause of acute abdomen with high overall predictive accuracy of 98.3% and sensitivity of 90%.
Plain x-ray abdomen was 100% diagnostic in GIT perforation, GIT obstruction, psoas abscess (caries spine)
and renal colic with overall predictive accuracy of 4.1% and sensitivity of 60%.
Ind J Radiol Imag 2005 15:1:109-115
Key words : - Acute abdomen, ultrasound, plain xray film
INTRODUCTION
Acute abdomen refers to presence of severe abdominal
pain developing suddenly or over a period of several hours,
and constitutes a significant percentage of emergency
admissions. The term encompasses within it, a long list
of differential diagnosis and poses one of the greatest
challenges to a clinician.
Acute abdomen has been divided into four subdivisions(1).
1. Lower abdominal pain:
Appendicitis
Mesenteric adenitis
Inflammatory bowel disease
Pain of unknown etiology
Gastroenteritis
Diverticulitis
2. Upper abdominal pain:
Cholecystitis
Ulcer perforation
Fitz Hugh Curtis syndrome
Pancreatitis
3. Gynecological emergencies:
Ectopic pregnancy
Corpus luteum rupture
Tubo ovarian abscess
Pelvic inflammatory disease
Endometriosis
Pelvic adhesions
Ovarian cyst

4. ICU patient pathology:

Acalculous cholecystitis
Perforation
Mesenteric ischemia
An early and accurate preoperative diagnosis is needed
for institution of prompt and appropriate management, in
order to limit morbidity and mortality.
AIM
1. To evaluate the role of plain x-ray film abdomen in the
diagnosis of acute abdomen.
2. To evaluate the role of ultrasonography in the diagnosis
of acute abdomen.
3. To correlate the radiographic findings with sonographic
features as to make the provisional diagnosis.
MATERIAL AND METHODS
A prospective study of 50 cases of non-traumatic acute
abdomen was done in order to compare the plain x-ray
film and ultrasound. Patients with trauma abdomen,
pregnant women, and patients with compromised vital
signs were excluded. A thorough clinical examination and
biochemical investigations were carried out.
Every patient was subjected to plain X-ray film abdomen
in supine, erect position, left lateral decubitus (wherever
required) and upright chest radiograph (wherever required).
Special investigations like intravenous urography, and
contrast studies of gastrointestinal tract were conducted
whenever necessary.

From the Department of Radio-diagnosis, Govt. Medical College, Amritsar

Request for Reprints: Dr. Kamlesh Gupta, Mahajan Villa, Vijay Nagar, Batala Road, Amritsar - 143001 (Pb)
Received 6 August 2003; Accepted 10 April 2004

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110 K Gupta et al
All the patients were then subjected to ultrasound
examination of abdomen.
Based on plain X-ray films and sonographic findings
provisional diagnosis was made. The final diagnosis was
made on the basis of operative findings/therapeutic
response/histopathological/laboratory findings. Finally the
accuracy of plain X-ray film abdomen and ultrasonography
in evaluating patients with acute abdomen was
determined.

6.

RESULTS
Table I shows that acute cholecystitis, acute appendicitis,
acute pancreatitis, gynaecological pathologies and
amoebic liver abscess were accurately diagnosed by
ultrasonography, whereas radiographic accuracy was
highest in renal cases.

7.

As shown in table II, it can be seen that ultrasound's

predictive accuracy was 98.3% and sensitivity (90%), plain
X-ray films predictive accuracy was 4.1% and sensitivity
(60%) whereas clinical diagnosis, accuracy was 70.9%
and sensitivity (83.3)%.
Based upon the observations made in 50 patients the
following observations were obtained.
1. There were 24 males and 26 females in varying age
groups in our series with a male to female ratio of
1:1.4.
2. Age of the patients varied from 6 weeks to 70 years
with a mean age of 37.6 years.
3. The Most Common Chief complaint was acute pain
abdomen in all the 50 cases (100%) and the least
common complaint of amenorrhoea was only in one
case (2%).
4. On clinical examination, 16 cases (32%) were
diagnosed as that of acute cholecystitis. 6 (12%)
cases of acute pancreatitis, 2 (4%) cases that of
amoebic liver abscess, 3 (6%) cases of acute peptic
ulcer, 13 (26%) cases as of acute appendicitis, 1 (2%)
case of ectopic pregnancy, 6 (12%) cases of renal
origin, 2 (4%) cases of intestinal obstruction and 1
(2%) case of hypertrophic pyloric stenosis.
5. On plain X ray film abdomen, 1 (2%) case was
diagnosed as acute cholecystitis, 1 (2%) as
appendicitis, 2 (4%) cases as G.I.T. perforation, 2
(4%) as G.I.T obstruction, 5 (10%) as renal lithiasis,
1 (2%) as caries spine with Psoas abscess. The
plain X ray film abdomen made no contribution in the
diagnosis of acute pancreatitis, hypertrophic pyloric
stenosis, gynaecological pathologies, amoebic liver
abscess. On ultrasound, 13 (26%) cases were
diagnosed as acute cholecystitis, 9 (18%) as acute
pancreatitis, 3 (6%) as amoebic liver abscess, 7 (14%)
as acute appendicitis, 1 (2%) as ectopic pregnancy,
2 (4%) as torsion ovary/cyst, 5 (10%) as ureteric

8.

9.

10.

11.

12.

13.

calculi, 1 (2%) as intestinal obstruction, 1 (2%)

hypertrophic pyloric stenosis, 1 (2%) as G.I.T.
perforation, 1 (2%) as pelvic collection, 1 (2%) as
psoas abscess.
Based on final diagnosis made after histopathological/
therapeutic/operative examination done wherever
necessary, we had 13 (26%) cases of acute
cholecystitis, 9 (18%) cases of acute pancreatitis, 3
(6%) cases of amoebic liver abscess, 8 (16%) cases
of acute appendicitis, 6 (12%) cases of gynaecological
pathologies, 2 (4%) cases of torsion ovary/cyst, 1
(2%) case of ectopic pregnancy, 1 (2%) case of pelvic
collection, 2 (4%) cases of tubo ovarian masses, 5
(10%) cases of renal origin, 2 (4%) cases of intestinal
obstruction, 2 (4%) cases of GIT perforation, 1 (2%)
case of hypertrophic pyloric stenosis and 1 (2%) case
of psoas abscess with caries spine.
In 13 cases of acute cholecystitis, plain X ray
abdomen was positive in 1 case only which showed
multiple radiopaque shadows in right hypochondrium
in the region of gall bladder. Sonographic findings of
cholecystitis were observed as thickened gall bladder
wall (more than 3 mm) with wall oedema in all cases,
Cholelithiasis in 12 cases, sonographic Murphy's sign
in 7 cases, sludge in 3 cases, pericholecystic
collection in 3 cases, CBD stone in 1 case. Thus
diagnostic accuracy of 100% was found in gall bladder
pathology on ultrasound.
Plain X ray film did not contribute to the diagnosis in
any case of acute pancreatitis whereas on ultrasound
7 (77.7%) patients showed diffuse increase in the size
of pancreas with diffuse hypoechoic echotexture.
Focal hypoechoic area was seen in 2 (22.2%) patients.
Complications of acute pancreatitis such as
pseudopancreatic cysts, were seen in 2 (22.2%)
patients. Gall stones were seen as associated
findings in 2 (22.2%) patients.
Plain X ray film abdomen diagnosed only 1 (12.5%)
out of 8 cases of acute appendicitis whereas
ultrasound diagnosed 7 cases with predictive accuracy
of 87.5%.
In 6 cases with gynaecological pathologies, plain X
ray was not contributory in any of the case whereas
ultrasound could correctly diagnose all the cases with
the predictive accuracy and sensitivity of 100%.
Plain X ray abdomen was contributory in diagnosing
all the 6 cases of ureteric colic and showed the radio
opaque calculi. On ultrasound renal/ureteric calculi
were seen in all the cases with demonstration of
hydronephrotic pelvicalyceal system.
Out of 3 patients of amoebic liver abscess diagnosed
only on ultrasound, 2 had single abscess and in 1
case had multiple abscesses. Plain X ray film did
not contribute any finding in cases with liver abscess.
Plain X-ray abdomen correctly diagnosed 2 cases of
intestinal obstruction and 2 cases of GIT perforation.
Whereas Ultrasound correctly diagnosed, 1 case of

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Comparative Study of Plain Film Abdomen and Ultrasound 111

intestinal obstruction, 1 case of GIT perforation and 1

case of infantile hypertrophic pyloric stenosis. Thus
proving that plain X ray film abdomen's predictive
accuracy and sensitivity was 100% in cases of GIT
perforation and intestinal obstruction.
14. Plain X ray abdomen and ultrasound both were
diagnostic in one case of psoas abscess with
predictive accuracy and sensitivity of 100%.
Ultrasound was highly accurate in diagnosing the exact
cause of acute abdomen with high overall predictive
accuracy of 98.3% and sensitivity of 90%, whereas plain
X ray abdomen was 100% diagnostic in GIT perforation,
GIT obstruction, psoas abscess (caries spine) and renal
colic with overall predictive accuracy 4.1% and sensitivity
of 60%.
It can thus be concluded that Plain X ray film can be
used as screening modality in the diagnosis of acute
abdominal emergencies as it is universally available, more
cheaper and was 100% diagnostic in GIT perforation,
obstruction and renal lithiasis. Ultrasound examination
is cheaper, non-invasive, quick, reliable and highly
accurate modality in diagnosing the exact cause of pain
and its origin in a patient presenting with an acute
abdomen and thus helps the physician or surgeon to plan
the timely management.
DISCUSSION
The comparative percentages in our study and study
done2 on 50 cases of acute abdominal emergencies.
SHOWING DISTRIBUTION OF CASES (AS PER FINAL
DIAGNOSIS)
Diagnosis %age of cases in study %age of cases in
2
by Walsh et al
present study
Hepatobiliary
34
32
Gut
32
26
Pancreas
10
18
Renal
10
10
Gynaecological
2
12
Others
12
2

Ultrasonography plays an important role in evaluating

patients of suspected acute cholecystitis with a reported
accuracy of 95 99%(4). 13 cases of acute cholecystitis
were correctly diagnosed on ultrasound when compared
with final diagnosis and positive co-relation was obtained
in 100% of cases.
The most sensitive criteria for diagnosis of acute
cholecystitis on ultrasound is the presence of gall stones
in association with focal gall bladder tenderness with
positive predictive value of 92%(4). Diffuse gall bladder
wall was present in all cases of acute cholecystitis but it
is a non specific finding as it can be found in many other
conditions unrelated to gall bladder disease like ascites,
hypoalbuminaemia, hepatitis, congestive heart failure,
renal disease, adenomyomatosis, polyps, carcinoma
etc(5). A plain radiography shows an incidence of 10 15%
radioopaque stones(6). Thus, a negative plain radiography
presents to be of little value in excluding gall stones. Only
15% of patients with cholelithiasis showed calcified stone
on a simple abdominal radiograph(7). In our study, gall
bladder stone was present in 1 (7.6%) out of 13 cases.
Ultrasound was successful in diagnosing all the 9 cases
of acute pancreatitis and with associated pseudocyst
seen in 3 cases (Fig. I). Clinically serum amylase levels
were raised in 7 patients only. This is a proved fact that
serum amylase value is not a specific pointer to diagnosis
of acute pancreatitis in patients with recurrent disease
enzyme levels may be low because of progressive
glandular destruction(8). It was also observed that out of
102 patients 36 (52%) patients showed diffuse
enlargement of pancreas, focal enlargement occurred in
the head 20 (28%) and in the tail in 14 (20%). Gall stones
were associated in 26% of patients with acute
pancreatitis(9) quite comparable to our study, where gall
stones were present in 2 (2l.2%) cases. The incidence of
pseudocyst was 22.2% in our series. Similar incidence
of pseudocyst was 11-18%(10).

16 out of 50 cases were of hepatobiliary origin i.e. 32%

and comprised the largest group. This was followed by
conditions of gut which comprised 26% of our cases and
acute pancreatitis in 18(2).
Accuracy of clinical diagnosis:
In our series the positive predictive clinical accuracy and
sensitivity were variable and unpredictable, the overall
predictive accuracy of clinical diagnosis was 70.9% and
sensivity was 83.3%, comparable with previous studies3.
It was found that clinical diagnosis in cases of acute
abdominal emergencies ranged from 40 69.9%.

Fig. No. 1. Ultrasonographic Films Showing A Case Of Acute

Pancreatitis With Pseudocyst Formation Before And After
Ultrasound Guided Drainage Procedure

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112 K Gupta et al
In the present study, plain X-ray film was diagnostic only
in 1 (12.50%) case out of 8 patients of appendicitis. The
result was comparable to the earlier study where it was
reported the appendicolith by plain abdominal x-ray films
in 7 to 14% patients of acute appendicitis(11).
Sonographic criteria for acute appendicitis include
visualization of a non compressible appendix with
maximum outer diameter >6 mm or visualization of an
appendicolith within an appendix of any size, quite
comparable with our study where in 5 out of 8 patients
non compressible appendix was visualized with average
outer diameter of 8.8 mm (Fig. II). Appendicolith was
visualized in 1 patient only . In 1 patient, localised well
circumscribed fluid collection was found, suggestive of
appendicular abscess. In 1 out of 8 patients, ultrasound
study was normal but acute appendicitis was diagnosed
at surgery. Out of 90 patients with clinically suspected
acute appendicitis, three patients were considered to
represent false negative sonographic diagnosis(12). In
our study 1 patient out of 8 suspected cases of appendicitis
which was considered to represent false negative
sonographic diagnosis was proved to be acute
appendicitis at operation. Thus, the predictive accuracy
of ultrasound was 83.3% and sensitivity was 100%,
comparable to the reported sensitivity in acute appendicitis
80 89%(13).

IJRI, 15:1, February 2005

peritonitis where free fluid with echoes was seen on
ultrasound (Fig. III-ii). There were 2 cases of
gastrointestinal perforation diagnosed on plain X ray film
abdomen as compared to 1 case which was diagnosed
on ultrasound where air was seen as an echogenic line
beneath the diaphragm and another case showed free
fluid with soft internal echoes. Thus, the predictive
accuracy and sensitivity was 100% on plain X ray film
abdomen. The extraluminal air of a perforated hollow
viscus is visible in only 50 70% cases in plain X ray film
abdomen(15). On ultrasonography pneumoperitoneum
appeared as an echogenic line beneath the anterior wall
of abdominal cavity, associated with characteristic
posterior shadowing or reverberation artefact. It is possible
to detect as little as 1 to 2 ml of free air(16).
Pneumoperitoneum can be demonstrated in nearly 90%
of cases on plain radiography(17). Abdominal radiographs
sensitivity approaches 100% in cases of bowel
obstruction and free peritoneal air(18).

Fig. No. 2. Ultrasonographic Films (longitudinal and

transverse scan) showing dilated fluid filled and thick walled
appendix in a case of acute appendicitis

1 case of infantile hypertrophic pyloric stenosis was

diagnosed by ultrasound and confirmed by surgery. Plain
X ray abdomen did not help in diagnosing infantile
hypertrophic pyloric stenosis. Sonographically, thickness
of hypertrophied muscle from serorsa to mucosa is
considered the most reliable measurement for the
diagnosis of infantile hypertrophic pyloric stenosis.
Muscle thickness of 4 mm or more, diameter of
hypertrophied segment >15 mm and length of
hypertrophied segment of pyloric >17 mm was considered
diagnostic of hypertrophic pyloric stenosis. On transverse
section, the pylorus has an appearance of "Target or bull's
eye"(14). 2 cases of GIT obstruction, were diagnosed by
Plain X ray abdomen (Fig. III-i) as compared to 1 case by
ultrasound and another case was diagnosed as of

Fig. No. 3
(i) X-ray abdomen showing dilated gut with significant air
fluid level
(ii) Ultrasonographic film showing dilated air and fluid filled
coils of gut

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Comparative Study of Plain Film Abdomen and Ultrasound 113

In our study, there were 5 cases of acute abdomen with

pathologies of renal origin. Though plain X ray film showed
radio opaque calculi in all the cases, yet ultrasound
demonstrated the calculi with associated hydronephrotic
changes in all the cases (Fig. IV-i). 1 case of ureteric
calculi presented with acute abdomen showed complete
ureteric duplication with both the ureters inserting into
the bladder (Fig. IV-ii). Associated ureterocele was seen
which was demonstrated on IVP as well as on ultrasound
(Fig. IV-iii). One of the ureter was obstructed by two radio
opaque calculi as demonstrated on plain film. The bifid
collecting system is due to premature maturation of the
ureter and are of no clinical significance. If ureteric insertion
is obstructed with an associated ectopic ureterocoele,
which is a dilated intramural portion of the ureter which
appears on excretory urography as a smooth filling defect
arising from the lateral bladder wall giving the classic
"cobra head" sign(19). One case of pyonephrosis was
diagnosed on ultrasound where dependent echoes and
shifting debris were seen in collecting system (Fig. IV-iv).
The ultrasound is the modality of choice to detect dilated
collecting system which contains dependent echoes and
shifting debris(20).

(ii)

(iii)

(i)
Fig. No. 4
(i) Plain X-ray abdomen showing radio-opaque shadow in
left renal area
(ii) IVP film showing duplex left pelvicalyceal system with
uretrocele (cobrahead appearance) with ureterolithiasis.
(iii) U/S film showing dilated left terminal and intramural
portion of ureter projecting into urinary bladder, showing two
calculi with distal acoustic shadow
(iv) Left kidney showing severe hydronephrotic changes with
calculi with distal acoustic shadowing, soft and thick internal
echoes seen

(iv)

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114 K Gupta et al

TABLE I
SHOWING COMPARATIVE STUDY OF CLINICAL, RADIOGRAPHIC AND ULTRASONOGRAPHIC CO-RELATION
Disease
Acute cholecystitis
Acute appendicitis
Acute pancreatitis
Renal
Acute peptic ulcer
Amoebic liver abscess
Intestinal obstruction
Gynaecological pathologies
Infantile hypertrophic pyloric stenosis
Psoas abscess
Perforation

Clinical diagnosis

Radiographic diagnosis

U/S diagnosis

16
13
6
6
3
2
2
1
1
0
1

1
1
0
5
0
0
2
0
0
1
2

13

TABLE II
COMPARATIVE ACCURACIES OF CLINICAL DIAGNOSIS, X-RAY AND ULTRASOUND EXAMINATION
Sr. Diagnosis
No.

Predictive
Sensitivity Predictive Sensitivity Predictive Sensitivity
accuracy of
of clinical accuracy of of x-ray film accuracy of ultrasound
clinical diagnosis diagnosis % x-ray film %
%
of ultrasound
%
1. Acute cholecystitis
81.2
100.0
0.76
100.0
100.0
100.0
2. Acute pancreatitis
100.0
66.67
0
0
100.0
100.0
3. Amoebic liver abscess
100.0
66.7
0
0
100.0
100.0
4. Acute appendicitis
61.4
100.0
1.2
100.0
83.3
100.0
5. Gynaecological pathologies
16.6
100.0
0
0
100.0
100.0
6. Renal pathologies
83.3
100.0
100.0
100.0
100.0
100.0
7. Peptic ulcer (perforation)
66.6
100.0
100.0
100.0
100.0
50.0
8. GIT obstruction
100.0
100.0
100.0
100.0
100.0
50.0
9. Hypertrophic pyloric stenosis 100.0
100.0
0
0
100.0
50.0
10. Psoas abscess
0
0
100.0
100.0
100.0
100.0
11. Overall accuracy
70.9
83.3
4.1
60.0
98.3
90.0
cyst (Fig. V), 2 cases of tuboovarian masses, 1 case of
pelvic collection. One case of ruptured ectopic pregnancy
was diagnosed on ultrasound in our study which was
confirmed at surgery. Foetal heart activity could not be
demonstrated. Greater than 90% accuracy in diagnosing
ectopic pregnancy based upon classic sonographic signs
ectopic gestational sac, enlarged non gravid uterus and
free fluid in the cul de sac. Foetal heart activity is not
routinely demonstrated at early gestational age. Foetal
heart activity was possible in less than half of the
cases(21).

Fig. No. 4 Ultrasonographic film (longitudinal and transverse)

showing multiple cyst in right adenexa with soft echoes
(torsion ovarian cyst)

Plain X ray did not contribute to diagnosis in any of the 6

cases of with gynaecological pathologies. There was one
case of ectopic pregnancy and 2 cases of torsion ovary/

2 cases of adenexal torsion were suggested

preoperatively on ultrasound and were subsequently
confirmed at surgery when an adenexal mass changes it
previous position and is enlarged, then the diagnosis of
adenexal torsion was made. In torsion of ovary it was
seen as markedly enlarged mass and fluid can be
detected in cul de sac(22). In our study, all the 6
gynaecological cases were diagnosed by ultrasound, The
emergency ultrasonography is the most useful modality
in the diagnosis of female patients presenting with mid to
lower abdominal pain(23).

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Comparative Study of Plain Film Abdomen and Ultrasound 115

In the present study we found that 1 case of psoas

abscess presenting as acute abodmen showed
destruction of L4 and L5 vertebrae on plain X-ray,
ultrasonographically, hypoechoic collection was seen in
left renal area. Ultrasound was accurate in diagnosing
all the 3 cases of liver abscesses. Follow up scans were
done in all the cases. The abscesses reduced with
treatment with antiamoebic drugs and or aspiration. Thus
predictive accuracy and sensitivity of ultrasound was
100%. Comparable to accuracy rate percentage of
100%(24).
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