The Abdominal X-Ray

For: Nottingham SCRUBS 26th August 2 6

By: !an Bi"#le$ North Trent Radiology Training S"heme%

Contents:
Normal Anatomy Types of Projection Assessing the Film Technical Qualities Gas containing structures Solid Organs Bones Soft Tissues Presenting the film

Aims:
To identify and interpret significant a normalities on an a dominal !"ray #A$%&' and understand ho( this in)estigation relates to the o)erall management of the patient* +escri e the radiological appearances of common medical and surgical conditions on A$%*

The Abdominal X-Ray:

The a dominal !"ray #A$%& has a much more limited )alue in diagnosis than a chest !"ray* The radiation e!posure of an A$% compared to a ,$% is also considera ly higher* One A$% is e-ui)alent to ./ ,$%s* The A$% is of most use in the patient (ith an acute a domen* 0t may guide further imaging #Other 0maging 1odalities 2ecture& As (ith a ,$%' an appreciation of normal structures is )ital*

Abdominal X-Ray &ro'e"tions:

Supine 334 5rect 2ateral decu itus*

6no(ledge of the anatomy of the a domen allo(s locali7ation of the a normalities o ser)ed on the A$%*

Anatomy on the Abdominal X-Ray:

Abdominal X-Rays:

A$%"8

A$%"9

Abdominal X-Rays:

A$%".

A$%":

Film S(e"i)i"s and Te"hni"al Fa"tors:

The initial assessment of an A$% is the same as for a ,$%=

Film S(e"i)i"s:
Name of Patient Age ; +ate of Birth 2ocation of Patient +ate Ta<en Film Num er #if applica le&

Film Te"hni"al )a"tors:

Type of projection #Supine is standard& 1ar<ings of any special techni-ues used

Assess the Film in *etail:

A simple guide to interpretation is sho(n elo(* >or<ing through these headings one co)ers' ?dar< its@' ?(hite its@' ?grey its@ and ? right (hite its@ in turn*

+B,AC- B!TS. 0ntra"luminal gas can e normal* 5!tra"luminal gas is a normal* Ao(e)er' intra"luminal gas can e a normal if it is in the (rong place or if too much is seen*

Assess the Film in *etail:

+B,AC- B!TS. /Continued0 " Intra-luminal gas:
The ma!imum normal diameter of the large o(el is //mm* Small o(el should e no more than ./mm in diameter* The natural presence of gas (ithin the o(el allo(s assessment of cali er " although the amount )aries et(een indi)iduals* The caecum is not said to e dilated unless (ider than BCmm* 2arge and small o(el may e distinguished y loo<ing at o(el (all mar<ings' as sho(n in the o! elo(*

Assess the Film in *etail:

The haustra of the large o(el e!tend only a third of the (ay across the o(el from each side' (hereas the )al)ulae conni)entes of the small o(el tran)erse the complete distance*
Intra-luminal gas (continued): 0t is usual to see small )olumes of gas throughout the G0 tract and the a sence in one region may in itself represent pathology* For e!ample' if gas is seen to the le)el of the splenic fle!ure and nothing is seen eyond this' a site of the o struction at this site D a ?cut off@ point is noted*

Assess the Film in *etail:

Intra-luminal Gas:
Low Small Bowel Obstruction

Small Bo(el o struction*

Assess the Film in *etail:

0f o(el o struction is o ser)ed try to loo< for the cause* For e!ample a hernia as the cause of o struction*

Aernia*

Assess the Film in *etail:

Extra-luminal Gas:
>hen an o(el is o structed' or any other gas containing structure perforates' its contained gas ecomes e!tra"luminal* 5!tra"luminal gas is ne)er normal' ut may e seen follo(ing intra"a dominal surgery or endoscopic retrograde cholangio" pancreatography #5%,P&*

5!tra"luminal gas seen on erect ,$%*

Assess the Film in *etail:

Causes of Extra-luminal gas: Post A dominal SurgeryE5%,P Perforation of )iscus #eg* o(el' stomach& Gallstone ileus ,holangitis #infection (ith gas forming organisms& A scess

An ere"t CXR /not AXR0 is the best (ro'e"tion to diagnose a (neumo(eritoneum /gas in the (eritoneal "a1ity0%

Assess the Film in *etail:

+23!T4 B!TS. 5 Cal"i)i"ation Cal"i)ied stru"tures #?>A0T5 B0TS@& are often seen on A$%* The main -uestion is D does its presence ha)e any important implications* ,alcification can e roadly di)ided into . types=
#8& ,alcium that is an a normal structure " eg. gallstones and renal calculi #9& ,alcium that is (ithin a normal structure' ut represents pathology " eg. nephrocalcinosis' #.& ,alcium that is (ithin a normal structure' ut is harmless " eg. lymph node calcification*

Bones are normal ?(hite@ structures* On the A$% they comprise mainly those of the thoraco"lum ar spine and pel)is* Findings are largely incidental as direct one pathology (ould e in)estigated (ith specific )ie(s*

Assess the Film in *etail:

Pancreatic ,alcification

Gallstones

Assess the Film in *etail:

?G%5F B0TS@ G Soft Tissues
Soft tissues represent most of the contents of the a domen and feature hea)ily in the A$%* Ao(e)er' these tissues are poorly seen (hen compared to other imaging techni-ues such as ultrasound or ,T* The <idneys' spleen' li)er and ladder #if filled& can e seen in addition to psoas muscle shado(s and a dominal fat* %arely (ould action e ta<en on the asis of this imaging alone*

Assess the Film in *etail:

Splenomegaly

Assess the Film in *etail:

?B%0GAT >A0T5 B0TS@ G Foreign Bodies
Foreign Bodies represent an interesting final o ser)ation* O jects that may e seen include ingested and rectal foreign odies' items in the path of the !"ray eam such as elt uc<les' dress uttons and je(elry* Other o jects may ha)e een deli erately placed for e!ample an aortic stent' an inferior )ena ca)a filter or a suprapu ic urinary catheter* Sterili7ation clips and an intra"uterine de)ice are common findings in (omen*

Assess the Film in *etail:

Sterilisation and Surgical ,lips

Foreign ody per rectum

Finals %adiology ,ases= A dominal $"%ay

Case 6:
This HI year"old (omen presented to the surgical (ard (ith a distended a domen and )omiting*
&resent this 7-ray 8i1e a diagnosis and (otential "auses

Case 6: Ans9er
Radiology Re(ort:
Plain a dominal radiograph* 1ultiple dilated loops of small o(el (ithin the central a domen* Gas is not seen in the large o(el* No e)idence of hernia or gallstone to suggest potential cause of the dilated loops* These findings are in <eep (ith a lo( small o(el o struction* 0 (ould li<e to <no( if the patient has a history of a dominal surgery as the commonest cause is surgical admissions* The three commonest causes of small o(el o struction are= Surgical adhesions Aerniae 0ntraluminal mass eg' small o(el lymphoma or gallstone #in gallstone ileus&

Case 2:
This I8 year"old gentleman )isits his GP complaining of lood in his urine* Ae has had a num er of JT0@s in recent years*

&resent this 7-ray 8i1e a diagnosis and (otential "auses

Case 2: Ans9er
Radiology Re(ort:
Plain a dominal radiograph* T(o rounded radio"opacities measuring :cm (ithin the pel)is* Both opacities are smooth in outline' laminated in nature' ha)e the same density as one and project o)er the ladder* No other renal tract calcification* +oes the patient ha)e a history of neurogenic ladderK Gi)en the si7e of these stones and history of JT0@s these are ladder calculi* Bladder calculi are more common in those (ith a history of= JT0@s A neurogenic ladder Bladder di)erticulum

Case ::
This patient (as admitted (ith poor renal function*

&resent this 7-ray 8i1e a diagnosis and (otential "auses

Case :: Ans9er
Radiology Re(ort:
Plain a dominal radiograph 1ultiple areas of punctuate calcification project o)er the renal outlines ilaterally* The calcification is (ithin the medulla of the renal parenchyma* The ones are normal in appearance* These findings are consistent (ith nephrocalcinosis

,auses of Nephrocalcinosis include= Ayperparathyroidism 1edullary sponge <idney

There 9ill be the o((ortunity during the rest o) the day )or 4;4R<=N4 to (resent at least one AXR during the small grou( sessions%