Abdominal X-ray

WILLIAM BUNGA DATU, MD

 Plain abdominal x-ray imaging is an
abdominal examination without the use of
contrast with X-rays that describe the
structures and organs within the abdomen
(stomach, liver, spleen, colon, small
intestine, and diaphragm which are
muscles that separate the chest and
abdominal area
 To identify and interpret significant abnormalities
on an abdominal x-ray (AXR), and understand
how this investigation relates to the overall
management of the patient.

 Describe the radiological appearances of

common medical and surgical conditions on
AXR.

Aims
 Pregnant woman

Contraindication
 Film Specifics and Technical Factors:
The initial assessment of an AXR is the same as for a CXR:

Film Specifics:
•Name of Patient
•Age & Date of Birth
•Location of Patient
•Date Taken
•Film Number (if applicable)

Film Technical factors:

•Type of projection (Supine is standard)
•Markings of any special techniques used
 • Supine 99%
• Erect
• Lateral decubitus.

 Knowledge of the anatomy of the

abdomen allows localization of the
abnormalities observed on the
AXR.

Abdominal X-Ray Projections:

Anatomy
on the
abdominal
x-ray
AP supine
 The position of AP to see the
distribution of intestines, preperitonial fat,
presence or absence of spreading. The
description obtained is the widening of the
intestine in the proximal obstruction area,
thickening of the intestinal wall, image
like a fish bone (herring bone appearance)
left lateral decubitus
 LLD position, to see air fluid level and
possibly intestinal perforation. From the
air fluid level may be suspected intestinal
passage disorder. If the short- air fluid
level means there is a high ileus, while if
the length of possible disturbances in
colon. The picture obtained is the
presence of free air infra diaphragm and
air fluid level.
errect
 Half-sitting or errect position to see
radiological features of air fluid level and
step ladder appearance. Thus radiological
features of obstructive ileus include partial
bowel distension, air fluid level, and
herring bone appearance.
 There are a number of significant
abdominal conditions that should not be
missed :
1. Bowel gas pattern (black bits)
- intraluminal gas
- extraluminal gas
2. Calcified structure (white bits)
3. Bones (white bits)
4. Soft tissues (grey bits)
5. Foreign bodies (bright white bits)

Assess the Film in Detail

Bowel gas pattern
Small bowel
35mm

Central
position

Many loops
Fluid level on
erect film :
many

Bowel
markings :
Valvulae
conniventes
 Free air :
Perforation of an
intra-abdominal viscus is a
surgical emergency and
almost always requires
intervention
As little as 1ml of
free intraperitoneal air can
be detected on the erect
chest radiograph

Bowel gas pattern

 Causes of Extra-luminal gas:
• Post Abdominal Surgery/ERCP
• Perforation of viscus (eg. bowel, stomach)
• Gallstone ileus
• Cholangitis (infection with gas forming
organisms)
• Abscess
 Detection of intra-
abdominal free air on the supine
AXR can be challenging. Rigler’s
sign describes the presence of
air on both sides of the bowel
wall and is a reliable indicator of
free intra-peritoneal air. This is
appreciated by looking at the
bowel wall and establishing that
an air density is present on both
the mucosal and serosal
surfaces.
Falciform Ligament Sign.
Normally the
falciform ligament is
surrounded by soft tissue and
therefore is not visible on the
abdominal radiograph.
However, if there is free air in
the abdominal cavity, it
surrounds the falciform
ligament making it visible. In
the example above, the
falciform ligament is clearly
outlined by air (black arrows).
 Small bowel
obstruction with perforation.
Note the dilated loops of bowel
centrally within the abdomen.
There are mucosal folds
spanning the entire width of the
bowel wall indicating these
represent loops of small bowel.
There is an ovoid air density
projected over the upper
abdomen which is called the
“Football Sign” (black arrows)
and is in keeping with massive
pneumoperitoneum

obstructions
 Large bowel
obstruction – open loop.
There is a dilated loop of
large bowel in the right side
of the abdomen – note the
mucosal folds do not cross
the entire width of the bowel
wall. There is also small
bowel dilatation centrally
within the abdomen
indicating that the ileocaecal
valve is incompetent. This
patient was found to have an
obstructing colonic tumour at
the hepatic flexure.
 Sigmoid volvulus. There is a large gas filled loop of featureless
sigmoid colon arising from the pelvis which is associated with distension
of the proximal colon. A sigmoid volvulus was suspected and a water-
soluble contrast enema was performed. Lateral radiograph from a water
soluble contrast enema study. Note the beak-like tapering at the anterior
extent of the contrast column (arrow) – this represents the twist in the
colon and is often referred to as the “Bird of Prey sign”
Caecal volvulus. This
classic radiograph
demonstrates
a featureless dilated gas
filled viscus,
representing the volved
caecum, in the left
upper quadrant (black
arrows) and small bowel
obstruction (white
arrows). No colonic gas
is identified.
Necrotizing
enterocolitis
(NEC)
Single bubble
appearence
Double bubble
appearence
 Calcified structures (‘WHITE BITS’) are often seen on
AXR. The main question is – does its presence have
any important implications. Calcification can be broadly
divided into 3 types:
◦ (1) Calcium that is an abnormal structure - eg. gallstones and
renal calculi
◦ (2) Calcium that is within a normal structure, but represents
pathology - eg. nephrocalcinosis,
◦ (3) Calcium that is within a normal structure, but is harmless - eg.
lymph node calcification
 Staghorn Calculi, no
contrast has been
administered to this
patient. The dense
calcification seen in
both collecting systems
represents renal calculi
(white arrows).
Incidental note is made of
a gallstone in the right
upper quadrant
(black arrow). Note the
difference in the shape
and type of
calcification seen in
gallstones.

Calcificated structure
Phleboliths represent small venous mural
calcifications. They
occur in approximately 40-50% of patients
and their incidence increases with age.
However, they can be confuse with distal
ureteric calculi and so it is important to
identify
and dismiss them. A phlebolith is typically
round or ovoid
in shape and may have a lucent centre
unlike renal calculi
which are irregular in both shape and
outline and are usually
of a uniform high density. Due to the natural
course of the
ureter it can be assumed that a calcification
below the level of the ischial spines is a
phlebolith.
Foreign bodies per rectum
 Barry James; Barry Kelly.2013. The
abdominal Radiography:179-187, The
Ulster Medical Society.
 Dwitya Rilianti.2017. Radiografi abdomen
tiga posisi Pada Kasus Neonatus Dengan
Meteorismus. Medical Unila vol 7 No.2
:42-47.
Thank u so much….