abdomen xray

7/25/2019 Abdomen Xray

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Abdominal X-rayRadiological Signs

Suzanne OHagan


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Lightbulb momenta moment of sudden inspiration, revelation, or recognition


3/82

Approach to AXR

Bowel gas pattern

Extraluminal air

Sot tissue masses

!alci"cations


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Normal AXR

11th

rib

Hepatic flexure

Gas in

stomach

T12

Gas in caecum

Iliac crest

Femoral head

SI oint

Gas in sigmoid

Transverse colon

Splenic flexure

!soas margin

Sacrum

"eft #idne$

"iver

%ladder


5/82

#as pattern

Stomach& Almost always air in stomach

Small bowel& Usually small amount of air in

2 or 3 loops

Large bowel& Almost always air in rectum

and sigmoid

& Varying amount of gas in rest of large bowel

'hat is normal(


6/82

Normal uid le!els Stomach

& Always "upright# decub$

Small bowel

&%wo or three le!elsacceptable "upright# decub$

Large bowel

& None normally"functions to remo!e uid$


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Large !s small bowel

Large bowel

& &eripheral "e'cept RU( occupied by li!er$

& )austral mar*ings don+t e'tend from wall

to wall

Small bowel

& ,entral

& Val!ulae conni!entes e'tend across lumenand are spaced closer together


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Radiographic principles

Series of -lms for acute abdomen

.bstruction series/ Acute abdominal

series/ ,omplete abdominal series

& Supine "almost always$

&Upright or left decubitus "almost always$

& &rone or lateral rectum "!ariable$

& ,hest# upright or supine "!ariable$


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$%E& 'OO( )OR

SU&0N1 A.41N owel gas pattern,alci-cations4asses

&R.N1 A.41N 5as in rectosigmoid5as in ascending anddescending colon

U&R05)% A.41N 6ree air# air7uid le!els

U&R05)% ,)1S% 6ree air# lung pathologysecondary tointraabdominal process

Acute abdominal series8hat to loo* for

Substitutes9 &rone Lateral rectumUpright Left lateral decub

Upright chest Supine chest


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.btaining !iews Supine

& &atient on bac*# ' ray beam directed

!ertically downward# casetteposterior# '7ray tube anterior "A&$

&rone

& &atient on abdomen# '7ray beamdirected !ertically downward#cassette anterior# '7ray tubeposterior "&A$

Upright

& &atient stands or sits# '7ray beamdirected hori:ontally# cassetteposterior# '7ray tube anterior "A&$

Upright chest& &atient stands or sits# hori:ontal '7

ray beam# cassette anterior# '7raytube posterior "&A$

1900s X-Ray-based fluoroscopy machine

in which radiation is shot directly through

the patient and into the doctors face.


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Abnormal 5as &atterns

6unctional ileus& .ne or more bowel loops become aperistaltic

usually due to local irritation or inammation

Localised ;sentinel loops< "one or two loops$ 5eneralised "all loops of large and small bowel$

4echanical obstruction

& 0ntraluminal or e'traluminal Small bowel obstruction

Large bowel obstruction


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*+ ,+ R.'E

/aximum 0ormal 1iameter o

bowel

Small bowel 3cm

Large bowel =cm

,aecum >cm


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Localised ileus?ey features

.ne or twopersistentlydilated loops of small orlarge bowel "multiple !iews$

.ften air7uid le!els insentinel loops

Local irritation# ileus insame anatomical region as

pathology 5as in rectum or sigmoid

4ay resemble early S.


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,auses of Localised 0leusby location

S%2E O) 1%'A2E1

'OO3S

!A.SE

Right upper@uadrant

,holecystitis

Left upper @uadrant &ancreatitis

Right lower @uadrant AppendicitisLeft lower @uadrant i!erticulitis

4id7abdomen Ulcer or *idney/uretericcalculi


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,olon cut o sign

)xplanation*

Inflammator$ exudate in acute

pancreatitis extends into the

phrenicocolic ligament via lateral

attachment of the transverse

mesocolon

Infiltration of the phrenicocolic

ligament results in functional

spasm and+or mechanicalnarroing of the splenic flexure at

the level here the colon returns

to the retroperitoneum-

.brupt cutoff of colonic gas column at the splenic flexure /arro0- The colon is

usuall$ decompressed be$ond this point-


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5eneralised ileus?ey features

1ntire bowel aperistaltic/hypoperistaltic

ilated small bowel and large bowel torectum "with L. no gas in rectum/sigmoid$

Long air7uid le!els

!A.SE RE/AR(

B&ostoperati!e Usually abdominal surgery

1lectrolyte imbalance iabetic *etoacidosis

almost ala$s


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5eneralised adynamic ileus

The large and

small boel are

extensivel$ airfilled

but not dilated-

The large and

small boel loo#

the same-


18/82

4echanical S.

ilated small bowel

6ighting loops "!isible loops# lyingtrans!ersely# with air7uid le!els atdierent le!els$

Little gas in colon# especially rectum


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S. 1rect S. Supine

.ir fluid levels


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,auses of 4echanical S.

B 4ay be !isible on AXR

Adhesions

)erniaB

4alignancy

5allstone ileusB

0ntussesception

0nammatory bowel

disease


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Step ladder appearance

Loopsarrange

themsel!esfrom leftupper toright lower

@uadrant indistal S.


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,oil spring sign


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String of pearls sign

3onsidered diagnostic of obstruction /as opposed to ileus0

and is caused b$ small bubbles of air trapped in thevalvulae of the small boel-


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Stretch/slit sign

Slit of air caught in a

valvulae, characteristic

of S%4


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,losed loop obstruction

%wo points of same loop of bowelobstructed at a single location

6orms a , or a U shape

&%erm applies to small bowel# usuallycaused by adhesions

& Large bowel# called a !ol!ulus


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,rescent Sign

3aused b$*

"56 Soft tissue mass

47

Head of intussusception

in distal transverse colon


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ouble ubble Sign

8uodenal .tresia


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4echanical L.

,olon dilates frompoint of obstructionbac*wards

Little/no air uidle!els "colonreabsorbs water$

Little or no air inrectum/sigmoid


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Large bowel obstruction

%oel loops tend not to

overlap therefore

possible to identif$ site

of obstruction

"ittle or no gas in small

boel if ileocaecal valve

remains competent

If incompetent, large boel

decompresses into small boel, ma$

loo# li#e S%4


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,auses of 4echanical L.

%U4.UR

V.LVULUS

)1RN0A

0V1R%0,UL0%0S

0N%USSUS,1&%0.N


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Note on !ol!ulus

Sigmoid colon has its own mesentrytherefore prone to twisting

,aecum usually retroperitoneal andnot prone to twistingC 2DE peopleha!e defect in peritoneum thatco!ers the caecum resulting in amobile caecum

V l l


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Vol!ulus. volvulus ala$s extends aa$from the area of tist-

Sigmoid volvulus can onl$ move upards and usuall$

goes to the right upper 9uadrant- 3aecal volvulus

can go almost an$here-


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,oee ean SignSigmoid !ol!ulus

:assivel$

dilatedsigmoid loop


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)ernia

"ateral decubitus of valueThe advantage is that there ma$ be a greater chance of air entering theherniated boel because it is the least dependent part of the boel in the

supine position-


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Apple core sign

Radiologic manifestation ofa focal stricture of the bowelusually at contrast materialenema e'aminationF %he

stricture demonstratesshouldered margins andresembles the core of anapple that has been

partially eatenF %he mostcommon cause is anannular carcinoma of thecolonF


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%humbprinting

The distance beteen

loops of boel is increased

due to thic#ening of the

boel all-

The haustral folds are ver$thic#, leading to a sign

#non as ;thumbprinting-;


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Lead pipecolon

Shorteningof colonsecondary to-brosis

Loss ofhaustration

Ulcerati!ecolitis


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Extraluminal air %G&1S

& &neumoperitoneum/free air/intraperitoneal air

&Retroperintoneal air

& Air in the bowel wall"pneumatosisintestinalis$

& Air in the biliary system "pneumobilia$


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Upright -lm best

%he patient should be positioned sittingupright for HD72D minutes prior toac@uiring the erect chest X7ray imageF

%his allows any free intra7abdominal gasto rise up# forming a crescent beneath

the diaphragmF 0t is said that as little asHmlof gas can be detected in this wayF


40/82

6ree Air,auses

Rupture of a hollow !iscus& &erforated peptic ulcer

&%rauma& &erforated di!erticulitis "usually seals o$

& &erforated carcinoma

&ost7op I7J days normal# should get less withsuccessi!e studies BN.% ruptured appendi' "sealso$


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Signs of free air

,rescent sign ,hilaiditis sign

Riglers "and 6alse Rigler+s$

6ootball sign 6alciform ligament sign

%riangle sign

,upola sign

Lesser sac sign


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,rescent Sign 00Free air under the diaphragm

%est demonstrated on

upright chest x ra$s or

left lat decub

)asier to see underright diaphragm


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,hilaiditis sign

4ay mimic air under

the diaphragm

Loo* for haustral folds

5et left lat decub to

con-rm

In patients ho have cirrhosis

or flattened diaphragms due to

lung h$perinflation, a void is

created ithin the upperabdomen above the liver- This

space ma$ be filled b$ boel- If

this boel is air filled then it

ma$ mimic free gas-


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Rigler+s Sign%oel all visualised on both sides due to intra and extraluminal air

5suall$ large amounts of free air:a$ be confused ith overlapping loops of boel, confirm ith upright vie


45/82

6alse Rigler+s Sign

%he Rigler sign can sometimes besimulated by contiguous loops of bowel#whereby intraluminal air in one loop of

bowel may appear to outline the wall ofan adKacent loop# which results in amisdiagnosis of free airF

4easure distance of interface if unsure


46/82

6ootball S0gn

Seen ith massive

pneumoperitoneum

:ost often in children

ith necrotising

enterocolitis

!aediatric.dult

In supine position air

collects anterior to

abdominal viscera

l if li i


47/82

6alciform ligament sign


48/82

.ther patterns of air aroundli!er

8oge=s 3ap Sign


49/82

0n!erted V sign

.n the supine radiograph# an in!ertedV may be seen o!er the pel!isin apatient with pneumoperitoneumF

8hile in infants this is produced bythe umbilical arteries# in adults it

appears to be created by the inferiorepigastric !essels

,ontinuous diaphragm sign


50/82

,ontinuous diaphragm sign

Sufficient

free air, left

and right

hemi>diaphragms

appear

continous

L Si


51/82

Lesser sac Sign,upola Sign

Lessersacsign

& (blackarrows)The lesser sac ispositioned

posterior to the

stomach and is

usuall$ a potential

space- There is

free connectionbeteen the lesser

sac and the

greater sac

through the

foramen of

'inslo

Cupola

sign& (white

arrows)

.ir superior to

left lobe of

liver

8ouble %ubble Sign

, l Si


52/82

,upola Sign

%he term cupola comes from a dome such as

this famous dome of the uomo in 6lorenceF

.ir beneath the central tendon of the diaphragm

% i l Si


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%riangle Sign

%he trianglesign refers tosmall triangles

of free gas thatcan typically bepositionedbetween thelarge bowel andthe an*

R t it l Ai


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Retroperitoneal Air

Recognised by9

& Strea*y# linear appearance outliningretroperitoneal structures

& 4ottled# blotchy appearance

&Relati!ely -'ed position

4ay outline9

& &soas muscles

& ?idneys# ureters# bladder

& Aorta or 0V,& Subphrenic spaces


55/82

,auses of retroperitoneal air

owel perforation "appendi'# ileum#colon$

%rauma "blunt or penetrating$

0atrogenic

6oreign body

5as producing infection

& t it


56/82

&neumoretroperitoneum

%his patient has free air inthe retroperitoneal spaceF

%he air is seensurrounding the lateralborder of the right *idney"white arrow$F %here is

other e!idence of free gasincluding RiglerMs signF

0f you are not con-dentthat the appearance ispneumoretroperitoneum#

you can try an erect anddecubitus !iew to see ifthe gas mo!esF 0f the gasis seen to mo!e# itMs not inthe retroperitoneumF


57/82

Air in t4e bowel wall

Signs

& est seen in pro-le producing a linearlucency that parallels the bowel

& Air en face has a mottled appearance

resembling gas mi'ed with faeculentmaterial


58/82

,auses of air in bowel wall

&rimary &neumatosis cystoides intestinalis "rare$

& usually aects left colon

& &roduces cyst7li*e collections of air in the submucosa orserosa

Secondary

& iseases with bowel wall necrosis

& .bstructing lesions of the bowel that raise intraluminalpressure

,omplications

& Rupture into peritoneal ca!ity

& issection of air into portal !enous system


59/82

&neumatosis intestinalis

0ntramuralair# bestappreciated

in pro-le


60/82

Air in the biliary tree

.ne or two tube7li*e branchinglucencies in the RU(# conform tolocation of maKor bile ducts

,auses


61/82

,auses

;Normal< if Sphincter of .ddi incompetence &re!ious surgery including sphincterotomy

or transplantation of ,

&athology "uncommon$& 5allstone ileus9 gallstone erodes through wall of

5 into the duodenum producing a -stulabetween the bowel and the biliary systemF

& Stone impacts in small bowel mechanicalS.F ;ileus< misnomer

iliary !s &ortal Venous Air


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iliary !s &ortal Venous Air

&ortal !enous airusuallyassociated withbowel necrosis

Air is peripheralrather thancentral

Numerousbranchingstructures

Sot tissue masses


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Sot tissue masses .rganomegaly

& ?now normal landmar*s

2 ways to identify soft tissue

masses/organs9

& irect !isualisation of edges of structure

& 0ndirect by displacement of bowel3T, 5S and :7I have essentiall$ replaced conventional

radiograph$ in the assessment of organomegal$ and soft

tissue masses

Abdominal


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Location &attern

Abdominal!alci"cations

6irst e'clude artefact


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6irst e'clude artefact

?im ?ardashian=s butt & real or artefact(

Location


66/82

Location Vascular

Li!er 5allbladder

Spleen

&ancreas

Lymph nodes

Adrenals

?idneys

Ureters

ladder

&rostate

Ri li*


67/82

Rim7li*e

,alci-cation that has occurred in the wallof a hollow !iscus

& ,ysts

renal# splenic# hepatic

& Aneurysms aortic# splenic# renal artery

& Saccular organs 5allbladder

Urinary bladder

3alcified h$datid c$sts


68/82

Linear/%rac*

,alci-cation in walls of tubularstructures

& Arteries

& 6allopian tubes

& Vas deferens

& Ureter

.ortoiliac calcification

,hi Si


69/82

,hinese ragon Sign

3alcified splenic arter$


70/82

,alci-ed !as deferens

6loccular Amorphous


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6loccular# Amorphous#&opcorn

6ormed in solidorgan or tumour& &ancreas "chronic pancreatitis$

& Leiomyomas of uterus

& .!arian cystadenomas& Lymph nodes

& Adenocarcinomas of stomach# o!ary# colon

& 4etastases& Soft tissue "pre!ious trauma# crystal

deposition$

,alci-ed ,alci-ed-b id


72/82

entericlymph nodes

-broids

,alci-edpancreas

Floccular


73/82

Lamellar or laminar

6ormed around a nidus inside hollowlumen

,oncentric layers due to prolongedmo!ement of stone inside hollow !iscus

& Renal stones

& 5allstones& ladder stones

ladder calculi


74/82

ladder calculi

"amellar

Renal calculi


75/82

Renal calculi!elvical$ceal calcifications

St h , l i- ti


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Staghorn ,alci-cation

7enal stones are often small, but if large

can fill the renal pelvis or a cal$x, ta#ing on

its shape hich is li#ened to a staghorn-Tubular

Renal calculi


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&utty ?idney

&utty *idney Osacs of casseous#necrotic material

"%$ Autonephrectom

y O small#shrun*en *idney

with dystrophiccalci-cation

Flocculent

,alci-ed gallstones


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,alci-ed gallstones

"amellar

, l i


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,onclusion

Approach to AXR should include gaspattern# e'traluminal air# soft tissueand calci-cations

Named radiological signs are a usefulway of remembering# identifying and

reporting on -lms

References


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References

)erring# 8F Learning Radiology 2nd1d# 2DH2

egg# PF Abdominal X7rays 4ade 1asy# H>>>

http9//wwwFwi*iradiographyFcom

http9//wwwFradiopaediaForg

http9//wwwFimagingconsultFcom

Roche# , et alF Radiographics9 Selections from the buet of food signs in RadiologyF No!2DD2# R5# 22# H3=>7H3Q

Goung# LF Radiology ,ases in &aediatric 1mergency 4edicineF Vol H ,a 2F %he %arget#,rescent and Absent Li!er 1dge SignsF

Raymond# et alF Radiographics9 ,lassic signs in uroradiologyF RSN 2DD

http9//wwwFswansea7radiologyFcoFu* Radiology %eaching SiteF 0ntroduction to abdominalradiography

4ussin# RF &ostgrad 4ed P 2DHH9 QJ92J72QJF 5as patterns on plain abdominal radiographs

http9//wwwFradiologymasterclassFcoFu*/tutorials/abdo/abdo'7rayabnormalities

4ettler9 1ssentials of Radiology# 2nd1d# 2DDI

http9//wwwFlearningradiologyFcom/radsigns

4uharram 6ood signs in radiologyF 0nternational Pournal of )ealth Sciences Vol H No HF Pan2DDJF
http://www.wikiradiography.com/http://www.radiopaedia.org/http://www.imagingconsult.com/http://www.swansea-radiology.co.uk/http://www.radiologymasterclass.co.uk/tutorials/abdo/abdo_x-ray_abnormalitieshttp://www.learningradiology.com/radsignshttp://www.learningradiology.com/radsignshttp://www.radiologymasterclass.co.uk/tutorials/abdo/abdo_x-ray_abnormalitieshttp://www.swansea-radiology.co.uk/http://www.imagingconsult.com/http://www.radiopaedia.org/http://www.wikiradiography.com/


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