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In the final part of our series we will focuson iatrogenic, accidental, and incidentalobjects seen on abdominal x ray films. These artefacts may be placed inside the body (internal) or be about the person(external). Internal objects may have beenplaced with intention by a health profes-sional or temporarily by the individual con-

cerned. Intentionally placed internalobjects may have required surgery or beeninserted through one of the bodys naturalorifices (mouth, vagina, anus). Incidental

objects are those that become projected onto the radiograph.

Iatrogenic objectsThese are placed intentionally by a healthprofessional.

A wide range of medical devices appear

on the abdominal x ray film, and many have been placed by radiologists themselves. Onsome occasions a radiographs sole purposeis to confirm the position of an object, such

as a tube device, most commonly the naso-gastric tube (figure 1). These are the most

commonly found iatrogenic objects, andtheir position is sometimes confirmed by achestx ray film.

Other devices may be in the vascular,hepatopancreatobiliary, gastrointestinal, and

Abdominal x rays made easy: iatrogenic, accidental,

and incidental objectsIn the final part of this series, Ian Bickle and Barry Kelly look at some of the more unusual findings on

an abdominal x ray film

Internal objects

Iatrogenic

Biliary or vascular stent

intrauterine coil devices

Sterilisation clips

Surgical clips

Greenfield filter (inside inferior venacava)

Percutaneous endoscopic gastrostomytube

Nasogastric tube

Accidental

Swallowed objects: razor blades,batteries, paper clips

Objects placed inside rectum orvagina: caps, bottles, vibrator

External objects

Incidental

Stoma ring

Objects in clothing: coins, keys, comb Objects on clothing: buttons, clips,

zips

Figure 1 (left) nasogastric tube clips fprrecent surgery and figure 2 (above)intruterine coil device in situ

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genitourinary systems.Evidence of vascular intervention may be

seen in the form of arterial stents and theplacement of filters in the venous systemforexample, the Greenfield filter placed in theinferior vena cava, which is used to preventrecurrent pulmonary emboli.

The hepatopancreatobiliary system is alsoroutinely stented, often for palliative relief ofobstructive jaundice secondary to neoplasm. The stenting is performed either by radio-logical percutaneous transhepatic cholan-giography (PTC) or by endoscopicretrograde cholangiopancreatography(ERCP).

A percutaneous endoscopic gastrostomy(PEG) tube may also be seen on an abdomi-nal x ray film.

In women, intrauterine coil devices and

sterilisation clips are readily seen in thelower half of the abdominal x ray film withinthe pelvis (figure 2). Tampons may alsoappear as tubular gaseous densities withinthe pelvis and should not be confused withanything more sinister.

Incidental objectsThese objects seen on an abdominal x rayfilms usually do not affect the wellbeing ofthe patient. These objects are externa;, theyare either attached to the patients body orcontained on or inside the patients clothes.Attached objects may indicate medical con-ditions, such as a stoma ring (figure 3) or

represent body art, such as a naval ring (fig-ure 4). Other incidental objects can be partof peoples clothing, such as buttons, zips,clips, or brooches.

Alternatively, the projected objects areinside a patients clothingin the case of theabdominal x ray film, usually a trouserpocket that has not be emptied before a filmis taken. These can be metallic objects suchas coins, paper clips, and keys, or otherdense objects such as a comb.

Accidental objectsThese are objects that have been placed in

the body by the individual concerned. Theobject then either remains in place andbecomes immovable or progresses furtherthrough the gastrointestinal tract and becomes lodged. Distinction can be made between objects swallowed or objectsplaced in the rectal or vaginal orifices. Onoccasion these objects may be retained for-eign bodies, such as a knife after a stabbing(figure 5).

Swallowed objects may be ingested inten-tionally or by misfortune. They usually travelthrough the gastrointestinal tract, but onoccasion they become lodged. Razor blades, batteries, coins, paper clips, and small toysare just a few of the potential objects (figure

6). Three chief groups of patients fall intothis categorypatients with psychiatric illhealth, children, and drug smugglers.

Per rectum (PR) objects, such as bottles,

vibrators, and light bulbs, are almost alwaysplaced inside the rectum for sexual pur-poses, only to become retained, requiringmedical attention for extraction (figure 7).

Ian Bicklepreregistration house officer, Barry Kellyconsultant radiologist, Royal Victoria Hospital, Belfast,

Thanks to Brian Grant, senior radiographer, Accident and Emergency Department, RoyalVictoria Hospital, Belfast

Figure 3 (top): stoma ring, figure 4 (above):navel ring, and figure 5 (below): a knife inthe abdomen

Figure 6: swallowed objects (3 cigarettelighters)

Figure 7: a bottle per rectum