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abdominal adhesions). A small bowel diameter on plain film greater than 30mm is considered
dilated.
Radiographic Technique
Appropriate views for an acute small bowel obstruction should start with a supine abdominal
plain film X-ray. It could be argued that all acute abdominal imaging should include an erect
AP/PA chest view to demonstrate pneumoperitoneum. There is also the possibility that the
abdominal symptoms are misleading.
No Radiological examination of the abdomen is complete without a
film taken to demonstrate the lung fields, as pulmonary consolidation
or cardiac conditions may mimic an acute abdomen
David Sutton textbook of Radiology"
Churchill Livingstone, Edinburgh, 1975
The erect abdominal plain film should be undertaken to clarify the appearances on the supine
image, or where there is a reasonable expectation of additional relevant findings (see
discussion below and here). The erect abdominal plain film should not be performed in
isolation under normal circumstances.
Where there are equivocal findings on the supine image, a repeat supine abdominal plain film
image can be very useful. It should be remembered that an abdominal image provides a
snapshot of the bowel at a particular point in time. If there is an equivocal or suspect
appearance, a repeat view taken as little as 10 minutes later will often confirm an appearance
as being pathological rather than a normal transient chance appearance.
A rarely utilised projection in the acute setting is the prone abdominal view. The advantage of
the abdominal plain film with the patient in the prone position is that the dependent and nondependent parts of the bowel are reversed. The disadvantage is that the patient is unlikely to
find the position comfortable.
The left lateral decubitus view is a suitable alternative to the erect abdominal view. A right
lateral decubitus or supine cross table lateral decubitus should also be considered in
appropriate circumstances.
A tangential view of external hernias can reveal incarcerated small bowel (see examples on
this page).
potential to include all of the upper abdomen (centre slightly more superiorly)
in a gasless obstruction, loops of fluid filled small bowel can be seen to drop under
the effect of gravity
The Poster
I have placed a poster on the wall of the X-ray viewing area in the Emergency Department as
shown below
This is a quotation from the abdominal plain film bible by Stephen R. Baker. His book titled
The Abdominal Plain Film is out of print but second hand copies are available from
Amazon. In my opinion it's well worth the money. We have a copy in our Radiology library
but it is continuously out on loan.
To summarise, the erect abdominal plain film can be very helpful in cases where the supine
findings are equivocal. Equally, its utility can range between not helpful and harmful in
patients whose diagnosis is clearly demonstrated on the supine image
The Role of CT
CT is the gold standard of diagnostic imaging in patients with acute abdominal symptoms.
Whilst a plain abdominal film can suggest a diagnosis of small bowel obstruction, CT is more
likely to reveal the cause and site of obstruction.
abdominal pain
belching
abdominal rigidity
abdominal swelling
Adhesions
Neoplasms
Hernias-external,
internal
Crohns
Other
asymmetry.
(Some texts will show hernias as the second most common
cause of SBO)
Treatment of SBO
The treatment of SBO will vary with the circumstances of individual cases. Insertion of a
naso-gastric tube into the patient's stomach is a common treatment. Some patients are treated
conservatively to see if the SBO will resolve spontaneously. Gastrografin has also been used
as a therapeutic agent in SBO. Surgical intervention is sometimes required.
Diagnostic Accuracy
The abdominal plain film is a blunt diagnostic tool. It has been likened to taking a patient's
temperature- an abnormal plain film appearance suggests that there is abdominal pathology
present much the same as a high temperature suggests that a patient has an infection.
The probability of a correct diagnosis by plain films varies from 55% to
80% with approximately equal likelihood of false-positive and falsenegative interpretations
Baker, S.R. The Abdominal Plain Film,
Appleton & Lange, 1990, p156
There is a good report on a study investigating the accuracy of the abdominal film in the
diagnosis of SBO here http://www.ajronline.org/cgi/reprint/188/3/W233
30mm
large bowel
50-60mm
caecum
90mm
The 3,6,9 rule is a very useful guide to determining when the bowel is dilated. It can also be
useful in distinguishing between small and large bowel. For example, if the small bowel
measures 90mm in diameter it is probably not small bowel.
is for
uncorrected
measurements.
The error
associated
with an
uncorrected
measurement
is usually not
a problem.
Where it can
be a problem
is in morbidly
obese patients
where the
small bowel is
situated close
to the
LBD/focal
spot.
If you perform
erect
abdominal
images PA
rather than AP
you may
identifying
small bowel
affected by
geometric
enlargement
demonstrated
on the supine
image
The important
finding in
SBO is a
change in
calibre of the
small bowel.
If the SBO is
sufficiently
obstructed,
the small
stretch/slit sign
bowel
proximal to
the
obstruction
will dilate.
Small bowel
with a
diameter
greater than
30mm is
considered to
be dilated.
Small bowel
can dilate up
to around
50mm. If the
small bowel
has a diameter
of 70mm or
greater it
probably isn't
small bowel.
The stretch
sign or slit
sign in which
a slit of air
caught in a
valvulae is
characteristic
of SBO.
The erect
abdominal
image will
show multiple
air/fluid levels
in dilated
small bowel
in patients
with SBO.
This is an
example of
SBO at
surgery. Note
that the bowel
is dilated
proximal to
the point of
obstruction
and collapsed
distal to the
point of
obstruction.
http://www.dhmc.org/dhmc-internet-upload/file_collection/10.20.04%20-%20Bowel%20Obstruction.pdf
featureless. A featureless
abdomen can be a result
of tumour or ascites. This
patient has a gasless rather
than featureless abdomen.
Note that the renal, liver,
psoas muscles and urinary
bladder outlines are
visualised
Note that this abdominal
film is not guaranteed to
be normal. It could
represent an early gasless
small bowel obstruction.
Clinical correlation is
required.
The small
bowel
demonstrated in
this image is
minimally
dilated
(36mm). There
is evidence of
loss of the
normal random
tessellated
pattern
associated with
undilated small
bowel. Instead,
the bowel is
showing signs
of a pattern
which is more
organised
rather than
random. There
are, for
example,
multiple loops
of small bowel
which have
become
aligned/parallel
.
This
appearance
may represent
an early small
bowel
obstruction or a
partial small
bowel
obstruction.
Clinical
correlation and
an erect film
may be very
helpful in
determining
whether the
appearance is
pathological.
This
appearance is
not typical of
generalised
adynamic ileus
although this
cannot be
excluded.
You could be
forgiven for
thinking that
this patient
has been
drinking
dilute
gastrografin.
This
appearance is
a gasless
small bowel
obstruction
and the
opaque
looking small
bowel loops
(white arrow)
are filled with
normal small
bowel
content, rather
than
gastrografin.
If you
compare this
image with
the gasless
small bowel
image above
you can see
that this small
bowel is
significantly
more
prominent.
There can be
difficulty in
distinguishing
an early
gasless small
bowel
obstruction
from a normal
appearance of
the small
bowel in
someone who
has just eaten
a large meal.
Clinical
correlation
and follow-up
imaging will
usually
provide
confidence in
the diagnosis.
The large
bowel is not
clearly
visualised
suggesting
that it may be
collapsed.
String-of-Pearls Sign
The curvi-linear arrangement of air
bubbles visualised on this image is
known as the string of pearls sign.
The appearance is considered to be
diagnostic of obstruction (as opposed
to ileus) and is caused by small
bubbles of air trapped in the valvulae
of the small bowel.
Source:
Abdominal radiology [Hardcover]
James J. M.D. McCort , Robert E. M.D. Mindelzun, Robert
G. M.D. Filpi , Charles M.D. Rennell
Williams and Wilkens 1981
p 117,148,151.
The String-of-pearls
sign [is] almost
always indicative of
intestinal obstruction
and is one of the few
situations in which an
upright or decubitus
film of the abdomen
contributes crucial
information about small
bowel obstruction.
Baker, S.R. The Abdominal Plain
Film,
Appleton & Lange, 1990, p156
Slit/Stretch Sign
This patient has a small bowel
obstruction. Apart from the solitary airfilled dilated central loop of small
bowel, there is also evidence of slit sign
or stretch sign (white arrows).
Slit sign is a result of small amounts of
air caught in the valvulae of fluid-filled
bowel. The subtle fluid filled loops of
small bowel and the slit sign are highly
suggestive of small bowel obstruction.
This appearance is deserving of an erect
abdominal projection. This patient had
one of the best string of pearl signs you
will ever see!
This is an erect PA
abdominal image. The
PA erect abdominal
projection has several
advantages:
There is
potential for the
patient to hold
onto the erect
bucky making
them feel safer
and more secure
It is easy to
adjust the tube
and bucky
position to a PA
chest position
The anteriorly
sited small
bowel and
transverse colon
will be close the
bucky/IR
reducing the
potential for
geometric
magnification
ingested gas in a
contained structure and
a horizontal beam are all
the necessary
requirements for an airfluid level on plain film
The appearance of
multiple air-fluid levels
on erect abdominal film
is sometimes referred to
as a step ladder sign. It
has also been suggested
that uneven levels in a
bowel loop (i.e. more
fluid on one side of the
loop than the other) is
diagnostic of SBO
rather than ileus. This is
refuted by some authors.
position. This
position may
be preferable
to the erect
lateral
position
shown below.
The
advantage of
the supine
decubitus
position is
that there may
be a greater
chance of air
entering the
herniated
bowel
because it is
the least
dependent
part of the
bowel in the
supine
position.
Gasless
incarcerated
small bowel
in an external
hernia may be
difficult to
visualise.
An aluminium
filter covering
the herniated
bowel is very
useful when
imaging
abdominal
hernias in a
tangential
projection.
Also, DR is
better than
CR, and CR is
better than
film/screen.
This patient
presented to
the
Emergency
Department
with a similar
history. The
radiographer
has performed
an erect
lateral
abdomen
revealing an
umbilical
hernia
containing
small bowel
and an
air/fluid level.
The herniated
abdominal
contents may
not appear to
contain bowel
if the bowel is
gasless.
Case 1
This 70
year old
lady
presented
to the
Emergenc
y
Departme
nt with
abdomina
l pain and
distensio
n. She
reported a
history of
bowel
cancer.
There is
stretch
sign
indicating
distended
fluidfilled
small
bowel
strongly
suggestiv
e of small
bowel
obstructio
n.
The large
bowel
contains
very little
faeces
and is
largely
gasless.
There
erect
abdomina
l plain
film
demonstr
ates
string-ofpearls
sign
which is
considere
d
pathogno
monic of
small
bowel
obstructio
n.
Further Reading
Unless I am mistaken, this is the best
textbook ever written on the abdominal plain
film. It is well referenced and written in a
readable style. It is out of print.
I have an older version of this book which I
purchased second hand through Amazon. It
was well worth the money!
I have also added the follwoing text onto my
wishlist...
Abdominal radiology [Hardcover]
James J. M.D. McCort , Robert E. M.D.
Mindelzun, Robert G. M.D. Filpi , Charles
M.D. Rennell
Williams and Wilkens 1981
Summary
Small bowel obstruction is a common pathology. A knowledge of the patterns of normal
small bowel and small bowel obstruction will assist in the interpretation of plain film
findings. Importantly, correlation with clinical findings, patient history, and other test results
can give an equivocal appearance additional meaning. Finally, the radiographer's knowledge
of normal and pathological appearance will allow him/her to make an informed decision as to
when supplementary views are justified and what views would be most suitable.
Latest page update: made by M.J.Fuller , Sep 11 2011, 4:58 AM EDT (about this
update - complete history)
Keyword tags: 3 3 6 9 rule 369 rule 6 9 rule adhesions adynamic ileus air-fluid
levels air-swallow bowel coiled spring crazy paving dependent dilated external
hernia gasless SBO gastrografin giraffe hernia hyperosmolar ileus incisional
hernia intussusception non-dependent obstruction pneumoperitoneum radiography
M.J.Fuller SBO slit sign small bowel stretch sign string of pearls succus entericus tessellated
umbilical hernia
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Thread Subject
erect abdominal
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Nov 23 2008, 9:40 PM EST by
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Erect Abdominal
imaging
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