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William Herring, M.D.

2002

Plain Films
Of the Abdomen
An Approach

In Slide Show mode, to advance slides, press spacebar

What to Examine

Gas pattern

Extraluminal air

Soft tissue masses

Calcifications

GESC

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

Gas in
stomach

Gas in a few
loops of
small bowel

Gas in
rectum or
sigmoid

Normal Gas Pattern

Normal Fluid Levels

Stomach

Small Bowel

Always (except supine film)

Two or three levels possible

Large Bowel

None normally

Always
air/fluid level
in stomach

A few
air/fluid
levels in
small bowel

Erect Abdomen

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"

Complete Abdomen
Obstruction Series

Supine

Prone or lateral rectum

Erect or left decubitus

Chest - erect or supine

Complete Abdomen
Supine

Looking for

Scout film for gas


pattern

Calcifications

Soft tissue masses

Substitute none

Complete Abdomen
Prone

Looking for

Gas in rectum/sigmoid

Gas in ascending and


descending colon

Substitute lateral
rectum

Complete Abdomen
Erect

Looking for

Free air

Air-fluid levels

Substitute left
lateral decubitus

Complete Abdomen
Erect Chest

Looking for

Free air

Pneumonia at bases

Pleural effusions

Substitute supine
chest

Abnormal Gas Patterns

Functional Ileus

Localized (Sentinel Loops)

Generalized adynamic ileus

Mechanical Obstruction

SBO

LBO

Air in Rectum
or sigmoid

Air in Small
Bowel

Air in Large
Bowel

Localized
Ileus

Yes

2-3 distended
loops

Air in rectum or
sigmoid

Generalized
Ileus

Yes

Multiple
distended loops

YesDistended

SBO

No

Multiple dilated
loops

No

No

None-unless
ileocecal valve
incompetent

YesDilated

LBO

Localized Ileus
Key Features

One or two persistently dilated loops of


large or small bowel

Gas in rectum or sigmoid

Supine

Sentinel Loops

Prone

Sentinel Loops
Cholecystitis

Pancreatitis
Ulcer

Appendicitis

Diverticulitis
Ulcer
Ureteral calculus

Localized Ileus
Pitfalls

May resemble early


mechanical SBO

Clinical course

Get follow-up

Generalized Ileus
Key Features

Gas in dilated small bowel and large


bowel to rectum
Long air-fluid levels
Only post-op patients have
generalized ileus

Supine

Generalized Adynamic Ileus

Erect

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!

Mechanical SBO
Key Features

Dilated small bowel

Fighting loops

Little gas in colon, especially rectum

Key: disproportionate dilatation of SB

SBO

Mechanical SBO
Causes

Adhesions

Hernia*

Volvulus

Gallstone ileus*

Intussusception

*Cause may be visible on plain film

Mechanical SBO
Pitfalls

Early SBO may


resemble
localized ileus get F/O

Mechanical LBO
Key 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

Prone

Supine

LBO

Mechanical LBO
Causes

Tumor

Volvulus

Hernia

Diverticulitis

Intussusception

Mechanical LBO
Pitfalls

Incompetent ileocecal valve

Large bowel decompresses into small


bowel

May look like SBO

Get BE or follow-up

Supine

Carcinoma of Sigmoid LBO


Decompressed into SB

Prone

Air in Rectum
or sigmoid

Air in Small
Bowel

Air in Large
Bowel

Localized
Ileus

Yes

2-3 distended
loops

Air in rectum or
sigmoid

Generalized
Ileus

Yes

Multiple
distended loops

YesDistended

SBO

No

Multiple dilated
loops

No

No

None-unless
ileocecal valve
incompetent

YesDilated

LBO

Aunt Minnie Diagnoses

Air in
biliary
tree

SBO

Gallstone

Gallstone Ileus

Post-op C-section
Adynamic Ileus

Sigmoid Volvulus

Cecal Volvulus

Mesenteric Occlusion

Abnormal Gas Patterns


Ileus and Obstruction

Localized ileus

Generalized ileus

Mechanical SBO

Mechanical LBO

Extraluminal Air
Free Intraperitoneal Air

Signs of Free Air

Air beneath diaphragm

Both sides of bowel wall

Falciform ligament sign

Crescent
sign

Free Intraperitoneal Air

Air on both sides of


bowel wall Riglers
Sign

Free Intraperitoneal Air

Falciform
Ligament
Sign

Football sign

Free Intraperitoneal Air

Free Air
Causes

Rupture of a hollow viscus

Perforated ulcer

Perforated diverticulitis

Perforated carcinoma

Trauma or instrumentation

Post-op 57 days

NOT perforated appendix

Air in Lesser Sac

Extraperitoneal Air

Soft Tissue Masses

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

Splenomegaly

Myomatous Uterus

Hours
later

Bladder Outlet Obstruction pre- and post- cath

Mass in Cologastric Space - Pancreatic Pseudocyst

Right Renal Cyst

RLQ Abscess

Free Peritoneal Fluid- Bladder Ears

Abdominal
Calcifications

Abdominal Calcifications
Patterns

Rimlike

Linear or track-like

Lamellar

Cloudlike

Rimlike Calcification

Wall of a hollow viscus

Cysts

Aneurysms

Renal cyst

Aortic aneurysm

Saccular organs e.g. GB

Porcelain Gallbladder

Renal Cyst

Gallbladder Wall

Linear or Track-like

Walls of a tube

Ureters

Arterial walls

Atherosclerosis

Calcification Vas Deferens

Lamellar or Laminar

Formed in lumen of a hollow viscus

Renal stones

Gallstones

Bladder stones

Stone in Ureterocoele

Staghorn Calculi

Cloudlike, Amorphous, Popcorn

Formed in a solid organ or tumor

Leiomyomas of uterus

Ovarian cystadenomas

Nephrocalcinosis

Myomatous Uterus

What to Examine

Gas pattern

Extraluminal air

Soft tissue masses

Calcifications

The End