Abdominal

X-Rays
Made Easy
James D. Begg ae es FIlCll
Cc:nult.lntR.td ~,
~.. \ic1vN ~t.ll.

"""""
IIId Homr.ary Smior Lrctun'r in
~R.tdIl1logy.
l ni''f'r,jty Pl DJnd.." ,
Xu&rdt:K

A •
CHURCHill
LIVINGSTONE
En\BL'RCH I1X\TX JN MW,\,()l/.K J1 111.AIJHJ'-1IA snres 5YlY.\TI TORONlU I'HI
Contents

1. How 10look at an abdominal X-ray

2. Solid orga ~ 3;
3. Hollow organs 55

t Abnormal gas 86
5. Ascnes lI b
II. Abnnnnal intra-abdo minal calcification \HI

7. The fl;'mall' abdomen 154

8. Abl:h'minal lta uma 157

9. Ialmgt'nic objects 1M

10, Fi.lf\'ign bodjes, artl'fdcts. JJrisk>dJin~ illldg~ 170

11. The «ull' abdomm In
12. Hinh 17\1

Indn 183
 C a fer 1
How to look at an
abdominal X-ray
Ap roach to the film
• The init ial inspec tio n of an y X-ray be gin s w ith a technical assess ment.
Establishment (If the name, . .1.111;', date of birth, agl.' and sexof the pollit'nt at the
(lUtset is crucia l. There art' no prizes for making a brillia nt d iilgnos is in the
wrong patien t' Further information relati ng to the wa rd number OT hospi tal
of origin may give an idea as to the potent ialna tu re of the patient' s problem,
e,g. gastroin tes tina l Of urinary, .111 (I( which information ma y be visible on
the name badge, so never falltolock at it critically. Th is can be wry helpful
inexams. You will notice, however. that the dalilon the patients' name badges
in this book haw had 10 be Il.'ffiUVOO to preserve their anonymity.
• Establish the projection of 1111' film, Virtually t'wry abdominal X-ray is an AP
film, l.e. the beam p,l SSl'S from fro nt to back w ith the film behind the patient,
who is lying dow n wit h the X-ray m achin e overhea d . but these are freq uently
accompa nied by e rect or eve n dec ubi tus views (a lso APsl , Usually the
radiographer will ma rk the film wit h a badge or wri te on it by h and 'Su pine
or 'EI'l'Ct' to guide you, so seek this out and use it,
• Later on you must learn to work out for yourself how a given film wa s taken,
from the relative pos ition s of organs, fluid, gas etc.

NOthe standard 35• .0 em cassett e used to X-ray an ad ult is tan talisingly smaller
than theaVl'I'agl' normal human abdomen , and usu ally Iwo films all;' required to
get the entire anatomy included from the dia ph ragm to the groin s, Make sure
this has been don e before accept ing an y films for d iagnosis, If you don' t, you
will miss something impor tant and you wo n't know you've done it! In obese
patients casset tes may have to be used transversely, i.e. in 'landscape' as opposed
to 'portrait' mode. Rotation is nol usua lly a probl em as most patients art' happy
to lie on their backs.
Underpe netration is not usually such a pr oblem as in the chest. If yo u can
see the bones in the spine, then mos t of ever vthmg else you need 10 see will
 Approach to the fil m continued

probably be vislble as well. However; any overexposed (i.e. excessively dark)areas

on an X-ray must be inspected. again with a bright light behind them (built into
many viewing boxes for this purpose, or available as a separate device), as failure
to do so may cause you to miss something very importa nt, such as fret' air under
the diaphragm, representing a potentia lly fatal condi tion.
It is worth knowing that only five basic densities a re normally present on
x-reys, which 'lppear thus:

Gas black
Fot dark grey
Soft tissue/fluid light grey
Bone/ calcification white
Metal intense while

so you can tell from its densi ty wha t something is made of. There is, however, a
summa tion effect with large organs such as the liver which, because of their
bulk, can approach a bony densit y.
In the abdomen the primary structures outlined art' the solid organs, such as
the liver, kidneys and spleen; the hollow organs (i.e. the gastrointestinal tract);
and the bones. These structures can be classified as:

L Visible or not visible, and there fore whether presen t or potentially absent;
2. Too large or too small;
3. Distorted or d isplaced;
4. Abnormally calcified:
5. Containing abnormal gas, fluid or discrete calculi.

• Take a systematic approach and work your way logically through each group
of structures as a checklist. Initial inspection may reveal one or two major
and obvious abnormalities, but you must still drill yours elf to look through
the rest of the film - and you will frequently be sur prised. by what you find.
• Think logically.You should be able to Integrate your knowled ge of anatomy,
radiogra phic densi ty and pathology with the findings on the X-ray,a nd work
out what things are and what is going on.
• Look upon x-rays as an extension of physical examination, and rega rd
radiological signs as the equiva lent of physical signs in clinical medicine.

2
 The abd ominal X-ray: sca nning the fil m

The supine AP film

This is the film most frequentl y taken and shows mos t of the stru ctu res to the
best advantage. The optimum information can only be obtained from it by using
the correct view ing cond itions. An X-ray shou ld only ever be seriously inspected
by uniform tran smitted light coming th rough it, i.e. a viewing box . There is no
place for wa ving it about in the wind as irregula r illum inat ion a nd reflections
will prevent 10-20% of the use ful information on it being visualized.
Look for (Fig. 1.1):

• The bon es of the spine, pelvis, chest cagr.- (ribs) and the sacro-iliac joints
• The d ark margins ou tlining the liver, spleen. kidneys, bladder and PSOilS
muscle s - th is is intra -abdominal f,1I
• Gas in the body of the stomach
• Gas in the d escend ing colon
• The wide pe lvis, ind icating that the pa tient is fema le
• Pelvic p hlebolith s - norm al finding
• Minor joint space narrowing in the hips (norm al for this agel
• The granu lar texture of the amorphous fluid faecal matter containing pockets
of gas in the caecum, over lying the right iliac bone
• The 'R' marked low down on the right side. The marker can be anywhere on
the film and you often have to search for it. All references to 'right' and 'left'
refer to the 1\!/ifIlI'S righ t and left. Note the name badg e at the bottom, not
the top.
• Check that the 'R' mark er is com patible with the visible anatomy, eg
- liver on the righ t
- left kidney higher than the right
- stomach on the left
- spleen on the left
- heart on the left, when visible.
• The dark skinfold going right across the upper abdomen (nor mal).

,
 The abd ominal X..,.ay: scanning the film conl'nved

Hepatic Skin [, ;
Bexure liver fold kidney

Splenic
Ilell.ure

Gos in
-descending
<0100
_ Gos in body
of stomach

[,;
p>oo'
margin

--~"l!!!:i:!- Sccro-ilcc
joints

1I::=:i!~- ,,=* Bladder

_ Phlebolith

,
Fluid faeces and gas
in caecum

Fig. 1.1 - Adult supine AP radiograph in a 55·year· oldwoman.

5
 The abdom inal X-ray: scanning the film conlinved

Rugal
folds and
gas in
sto mach

Shadow of peni s (indicating llne of unfused

male childl and cndroid pelvis fe moral epiphysis

Fig. 1.2 - SupineAPradiograph of a child with leN·sided abdominal poin.

6
 The abdominal X-ray : scc nnin g the hlm conltn....,a

UklkJt( Fi~. 1,2):

• The 'rijo;ht' m arker at thetop left-haod corner of the film

• The heart ~h.1JIIW tin tfu- !\dID!' ~iJI' abo ve the right hemi dla ph ragm tdcvrro-
card ia)
• Theoutline \If the stomach f;ols and ruga l lolds 1m Ilk' right
• TbeIin-TI'" the Loft
• Unlu~ tl'lphy....... in tht' femora . This is d child \\'hr"'t' gro..... th is mcomp lcte ,
his small ..i / l' 1,·.IJinjo; to tht' inclusion tlf 1,"-, Ill.... W r hest and UPf'l'f th i ~hs o!s
well a~ all oi tho.- d~"n"..n - norrt'"ot'ntinio\a f"lrti.tl ·b.tbn~ra m' ",. il i" kno..... n
in raJK1K'KY'

\8 This \\;a.. rh't a T.lJi',;r,lrhic error ~l d ~t'n uint' "ilu.. inversus with 1.1t..;;'f..J
~lCitl._
As....ilh Itk- c~l or a limb, t-.t.lbli'ohmt'llt at left and right is t"""ol'!\haL You do
noc want ttl remove a fKll1J\dl "kim'y from rbe right side when it is the l~'(ln tht'
Irtl tlw t b.JI"lW....-d, MdU....•til a fdUlly X-ray (and thi!'o ha.. moo dollt.'!). Both in
f"Um~ and in clinical practin' ~ilu" inver..us, or mirror Iran!'oP'o",ilion of the
ibdomin.al contents. may tlfl1r be diJ~Tl(""",l'ol e m>m 1M apparmt iocompatitoihly
oflhr L/R mar\.t1' and lht-' ; ..rble,u\,llt.my wben it has been owrb>lt'IJ chnKally.
Tbe L/R mJrh,. I1\dY of (IlUN' be looJl1\'ctlyplaced ibdf as a result I,f radio-
j!;faphk error, and thi..haPP'o'Th \~rith di...u rt>in~ fm.IlWnt:'Y (t"Speridlly with limp..
in aswll~'l _ You mU'>lIht.'Tl ~(l bad. and clk'Ck \\ith tnto radiographt.-r fiN MtlT\'
ml!odiagnt.... m~ -uu.. mversu-, tll" unmu......,lrily n-qUt...ting a further X- ray• .\!'o.\
taull\· film ran 1-1' (w n,·lt, l wtth a pen. If in JuuM . n-evarnirwlbe p.ltit'TIt.

\I oroll: Alwol y' ( heck Irfl and right on r ,"rl)" film. (on<,(iou~I)· and rout inely -
t!oPfiully ju..t be fore ~urgiu l o~u l ion ...

7
 The abdominal X-roy: scan ning the film conli" .-1

look a t the bo ne s

These pr ovide a u....-ful ~l.lrl inf; fII linl with whic h r nos t students MI.' fdmili.n. and
J Tt' Tt'ldli\'t'ly constan t in appt."lTilnre. The lower most ribs.fu mbar spine , sacru m.
pt.'I\'i~ and h i ~ .HI.' all usuallv vi..ible to a ~11'i1 l!;'T UT It""t'l deg ree.
The ~hdf't' of the pt'h'i~ will inJ ira l!;' the ....-x of the pa tient . The bo nes may
also chow evidence (If ",'('onJa TyTTlilIif;lldnt disease, corticalthinning may reflect
oste0p'lTI)O;j~, and degenerative (ha n~t's will increase wi th the agt' (If the patient.
Overlying gas can be ,1 problem in the abdomen, l>bscuring genuine bom-
lesion... and !':1'Ot'Tatinf; fa l~' on e, (especially O\"l;'T the sacrum).
The di~o\"l'TY of Pagt'l'S Ji"l'd'.I.', myeloma or meta ...tatic di;,('il~', however;
willotten TTIiIh' YOUT search worthwhile.
Lt_,k at Wig. 1.3):
• The bones: the inilidl routine in..penon of the hone; showed an incidental
finJin g ( If l.'\ tt'TI-.iw ~11.'Tl.l';i ... in the right side oi the pelvis compared with
the other norma l sidt', and some slight bony expanston.

This is Pagt'!:' s disease, a pl'\'TTlilliglldnl condition in 1% of patients.

~f or;l l : Alw;lys chec k th e bon es .

8
 The abdominal X-ray: sca nning the fi lm c:oMn.-J

Fig. 1.3 - Unilolerol5C/erosis - right ltemjpelvis This is a 62·year-old mole

potient X-rayed for unexplained abodominal pain. No radiological coose was
Found onthe plain film ~ but endo~copy showed a duodenal ulcer.

9
The abd ominal X-ray: sca nning the film con lin.....d

Fig, 1.4 This is a 2().minvle IVU Film from a 68-year-old man with a craggy moss
palpable anteriorly on PRand haematvrja.

10
 The abdominal X-roy: sccnmng the film «Jfl~"..,.d

1.IIIIk dl (Fi);. IA ):

• The bonec tht.· f\' ,In' multiph- dense flri in the f'l'lvi!> a nd vertebrae of Iht'
lumb.u ~f'tnl·.

~'dft> typil'dl "dl'rllti~' lTk1d... t.I"l~ frum d carcinoma of the prostate.

\toral: Always chec k the bon e...

lotll<. .II IFi);. IS) :

• Thl' cxn-n ...ive dark m.,"'ri,ll ... u n"un di n~ a nd ~t.u l<.l y cllnl r,}~l in); with th e jo;ut
ilOO t"'f'l'idlly tht.·lo.iJllt·Y" , P"'"Jd,; muscles, live r i1nJ spleen .
Thl" 1'> the intrdf'l"liltlnt'al and retropernoneal fdl and it is thr~ that f\' ndt'r.> tbe
Wnry,; and p-otJd" mu-cle, vrsrblc on convenuonat X-ray Irlms. Conversely,
~I til thi.. tolt bv, fur t'umrl e, h.wrntJTTha};t' or lumOUT. will obscure
t~ll\iIrgin...
\8 The muTt' fal th.lt i-, pn.....-nt, the furtht'T thl' liJ~'" trnJ to be located
a....-. ~· from I"" ~pine. Thi .....huuM 0111 be rm..illl~'fJ'Tl'tt"l1 i1" p.lthological Ji!>pLKt--

""'"
-======; ; ; ; ; ; ; ;
_ Tip of liver wal
Abdominal
muscles
- Gut

· Block Innc-
cbdomnc l fat

_ Tip 01 spleen

_. Kidney
· Psoas muscle
· Exleflsor muscles
of spil'le

· lumbar vertebra

Fig. 1.5 Intra-obeJomil'lOl fa, This jJ 0 normal abdominal CTscan at !he levelof
the kidneyJ.

II
 The solid ns lviK e ral

look for the psoas muscles [Fig.l. l)

These form two of the few straight lint'S seen in the body. They form diverging
and expanding interface, exlt'nding infeftll.llt'rally from the lumbar ~pine 10insert
on the 1t'S'ol'r tnxharucrs of the femora . and are very important retropentoneal
landmarks. Thei r non-vtsuahzation may reflectserious di~',ISt', but there <If.' m,my
benign reasons why they m,ly not be visible, such as an t'X("t'SS of llVt'rlying g.lS,
curvature of the spine or a lar k of summnding f,lt. AI",d)"S look hard for them
but intt'rpn't their absence with caution.

took for the kidneys (Fig. 1. 1)

These are u~udlly seen as bean-shaped objects of soft-t issue dmsity high in tht'
ul'pt'r part of the abdomen. They art' usually smooth in outline, e\t.'nding from
the upper border of T12 on the left stdc to the lower border of L3 on the right
side, with the 1.,1\ kidnt>y Iring slightly higher than tfu- righl J.nd about 1.5 em
biAA.'r. Both kidntoys incline slightly rnt'tli.llly about 12" towards the spin.. oil their
upper poles. Normally they .ire wry mobile, m(l\'in~ dow n wi th inspiration,
,111<1dfl>ppin~ several centimetres in the erect position. A consctou-, effort must
dlw,]ys be made Itl find them, U~ud ll y, however, only pariS of their outlines an-
visible and you rnJy have to Illok \'l'1"Y ha rd to try and deduce exactly where they
lit, and how big they actually are. Ot:ra~hHl<llly the kidn..ys tlMy nurn1<l lly be
lobulated in outline. This 'fetallobu lation' molY then pll'ot' d iagnu~tir problems.

look fo r the liver (Fig. 1. 1)

Theliver, ht'ing.l solid org,m in the right uppt'r quadrant, presents as J large area
uf son-tissue den~ity, its bu lk usually preventing<lny bowel from occupying this
MI.',] . Therefore, anywhere that bowel is not present in tht' right upp..' r quadrant

is likely to rt'pn~'n t the hvcr. On O(T.l~illns, however, pow el can gl'l above the
liver and simulate a perfnr.ulon, i.e. 'Chilaiditi's syndrome', or colonic int er-
position.
Occasionally an anatornicallv large extension of the right lobe may occur,
hiking like ,I shark's fin, down into the right flank or Iliac fossa (,1 Rh... h-l's lobe).
This nMy well bo palpable dinically, but is not a true abnormality, Chronic

12
 Ih e solid orgo ns COI'IIrn"";/

ob-arccttve r Ulmtln,l ry d i....·,N· m.lYr ush tht' d iaphragm and liver down, crt'<lling
spuriuus ht'r"ltomt'gdly. NOlt' l>.lSdllung m.-. rki ngs an' etten visible through Ih.'
liwr.

Look for !he spleen (Fig. 1.11

This form.. a ....Ifl liSSUt' m.lss in Iht' It'll 1lrJ'l'f quadrant about the ..ize of th.'
patient's fl...1 or heart. It m.lY hl.' ...."" w t'll or pdrtiJlly tlb<.L-un'd, bUI in fact i..
ottt.'O nol -ecn .It 0111.
COlbidt'f.lbll' l;'T\1.:l~l'Ill'llt i.. Ol'(l"o... l~· IIIdl'll'd: it clinically kJl: . up to Ihrt'\'
uroe, nurmall, allhotlJl:h .. mal1t'1" d~n_ til enlargement II1.iI~' hi' ..hown on a
radiograrh Undl'!" favourableconditions . 5r1l'flic l'Ill.lrg.'m ent greater than 15 rrn
will tend to dLspl.Kt' .Id~ltvnt slrut1un"> and has m.m~' GIU.,..."

led:. for the b~o(Jder IFis, 1. II

\\lthin thl' pelvi.. .I I,Hgt' mass (If ....Iit-tb..ue dl'll ..ily ( fad i~a rh ica ll y water
Jt'lbii)o' '" .... >tt·h ....ue dl'll-..lh' . mJy be rn....'tlI.lS a ~ult IIIa full bldddt'f outlint.>d
by pt'ri\ 'e-ical jolt, dod in jl'ffidll~, evee nunnally, volume. up to two tnres may
cccur. pushing 0111 tilt.' gut up oIM 'JUt of till' tru e pelvi... If there is d'lObi as 10 the
natun" of ..uch a ma....a p'''I ,micturilillO film may ht· taken Of an ultra amd -can
J,:w. Bt-ing fullt" fluid, tlw tolokidt'1" behave.... r.wioJl:fdphKdlly Iik a llid ~n.

led:. for the ute rus

Thb fadit~faphicall~' .... llid vructure ..ib 110 hiP of and ma~' indent tho: tolokidt.... II
lNyoa:a..itlnall~' be ....'t'n ..pt.lnldnt'tlUsl~' dod i.. often well demon..trated indil\'ctl~'
al an IVU t'\Jmin,ltiun, (,lll"lng ,1 di ..unrt concavity on the uppt.'r t>dge of Ihl'
bladdt'J, In m,m~' patient.., hllwt'wr, il cannot be id..nnned on pla in film...

13
 The hollowviseere (gas-containing gastrointestinal troctl

On a normal film, any structure outlined by g,lSin the abdomen willbe part of the
~astmintt'stin,ll tract. Remember: on a supine AI' radiograph the pauent is lying
on his back, so under gravity ilny fluid will lie posteriorly within the gut and the
g,b in the bowel will float anteriorly on top of it.
NB fluid level s do nol appea r on su pine AP fil ms,
Failure to appreciate this mdY lead to ~mss misunderstanding and l'Hors in
diagnosis. To demonstrate fluid levels you need an /'reel film or a dl'ClJhilw; film
taken with a horizontal beam, Think systematkally and work your way down
through the gastrointestinal tract. identifying structures (rom the stomach to the
rectum.

look for the stomac h

ln the supine position, depending ()11 how much is present, the g,lS in the stomach
will rise anteriorly 10 outline variable volumes of the body and antrum of this
structure. to the left of and across the spine around the lowermost thoracic or
upper lumbar levels. Simultaneously the resting g<1strk fluid will form ,1 pool in
the fundus beneath the didphragm, posteriorly on the left-ha nd side, crt\lting a
circular uuthne - the 'gastrk pseudotumour - which should not Do.' mistaken for
an abnormal renal. adrenal or splenic m,I.SS, althuugh occasionally it is and
requests aft' received in X-ray to 'invl'Stigatt' the ldt upJX'r quadrant mass'. Try
to avoid this mistake. The mass can be made to disappear by turning thl' patient
prone or silting him upright, when the familiar fund ,11 g,IS bubble, commonly
bestseen on chest x-rays, will Jppe,lf with a fluid leveldirectly beneath the medial
aspect of the left hemidiaphragm (erect film).
Look at (Fig. l.h):

• The gas lying anteriorlv in the body of the stomach

• The fluid pool f'll':>!<,riorly - fhe g.lstric pseudotumour.
 The hollow viscera ton"nuttd

Gastric psevdotumour in
fundusof stomach

Gas in ~nt pori Gas in body

01 duodenum of stomoch

Fig 1.6 - This ;$ rile wpine radiograph 01 on odvh, ovrIin;rtg /he slomocn.

15
 The hollow vtscerc ,:c""",ued

Look at (Fig. 1.7):

• How the barium FIl.IC.lb in tht' fundus, l'\,IClly dS the I'{';.ting g.,l'>tric juiC'l' Jr".'"
on the plain film
• The largoamount of ~,l;. present, again in thl' body of the stomach. The patient
has in fact been given effl'r\'l~t'nt powder to generate excv-s carbon dioxide
to distend tht' stomach and generate 'd ouble contrast', i.e. an outline (If the
mucosa with barium and 1\.ls.
• How the fundus is seen only in 'single wntr.lst' on thiv view, i.e. barium
alone.

look for the small bowel

Because of f'l'fistal~i-s the outlinl' of the gils in thl' normal small bowel ts often
broken up into m,my small plll.'kl·ts which form plilygon,ll shapes, but oCCUpy.l
gt'llt'ralJy central location in the abdomen. when more distended, the cbaracterts-
nc'valvulaeconmventes', \,rroilloJ spring-shaped folds ,CT(l!'sing theenttre lumen
1Tlily be seen in the jejunum, although the normal ileum tends to remaln fl'dtull'l""s.
The calibre tlf the normal small bowel should not exceed 2.Scm-3cm, increa..ing
slightly dhot,llly.
Often wry little is seen (If till' small bowel on plain films. ,1S ill Figure 1.1 , and
it only becomes well visualised when abnormal.

16
 The hollow viscera COIlhn.-l

Barium pooling in fvndus

Gas in 00dy of stomach

Fig 1.7- This is a spal1iIm from a barium meal study with the patient supine-
me
eJl,octIy some paSltiotl os thepreceding film.

17
 The hollow viscera cor>,inuttd

took for the cppendix

'rou'Ilbclucky to find it!Occasionally this strurture w ill contain ,111 'appendicolith"

[i.e. calcified fM'C.11 m.ltl'rial) which may predispose the pauem to appendicitis
Lee, commonly ~.h will be pn....en t in the appt'ndi\, someurne, barium from a
recent Gl st udy, or even piece, of lead sho t which have been ingest ec'! and
Impacted themselves there.
If you see this (Fi~. 1.8) you ran then have a Iittlt' bit of amusement with your
patients, who will be amazed to know how you have figured out from their
abdominal X-rJY that tlwy have rec ently eaten g.lm", (t'K.1 rabbit or a pheasant).
Note: Retained barium in the appt.'ndi\ nnphcs the previous 'ldminblrd\inn
of barium, either otdlly or pt'r rectum. and implies su- pected GI tract disease. If
bar ium l'nh'rs the ap pendix. however, it implies that this mg,m is normal.

I Fig.1.8-Leodsholinopperldix
18
 The hollow viscera con';n.-}

look for the colo n [Figs 1. I and 1.9 )

1. Start with thecaecum in the ri~h l IliacfllS';'l. The-caecum ts the most dbll'nsib ll'
part of the colon and rec eives tluid material directlv from tht' ileum th Rlu ~h
the ileocaecal vain', The caecu m therefore nermallv contains semifl uid
mater ial nmta i nin~ mulliplt' pockets of gJ.sand , like much of the right sid",of
the bowel, assumes a gr,m ular ,1ppt>ilranCI' on X-rJYS, creating mottled a n ',lS
of g.Js....-en best .lg,lin:-I the background of the iliac bo ne. On occasions the
normal caecum rruy be l'mpty.
2. ,\8 The classic anJltl rnka ll,lyout of the colon j..; otten fnumi In ht> dt'\'i.lll't'!
from by tortuous and red undant bo.....el, but the hepatic and splenic flexure,
..huukl be idl'nli fi.lblt' ,IS the highl~1 fhed fltlint" on the right and lett ..idl;"'>,
n"'pt'cti\"t>ly. The tu n!,>\'t'!'>t· colon m.ay dip down dt't'ply into the pt'1\"i!'> , but
lilt' faecal content of the bowl'! become, increasingly solid and formed as on,'
pas"t's distally, eventuallv generati ng d iscrete masses which may be
indi\iJually idt>nlifit.J, but which always contain m.an y tiny POI:k!S gas. ,.f
3. Learn 10 idl'T\tify faecal material on abdominal X-r.l}'S tsee Fig. 3.1 01. Find tlro t
and you've found the ([I/,m, which m.ay be w ry important in film analysis,
particularly in diffen'fltiilting sm.all bowel from large bowel, These findin~s
can best No appreda red in severe «>nstif'iltinn with gnlSs faecal overload .
Somt'timt'S thb "ill involve the rectum (which is usually t'ITlpty in normal
iodi\iduals), when a 1.1~1' fat'Cal plug m.ay be present as...·..ociated with overflow
teconnnence.
.I. When visible the hdust ral fulds ,If the colon may be seen, only p.1rtially
\isualin.J acn....... part of the Ia~t' bowel lumen, although in ..... une P.lti''flts
Clllllpll'te en....sing of the lumen toy haustra m.ayoccur.

19
 The AP e rect film

Under the otfects of ~ravity much ch,ln~t>S wh en an abdominal X-ray ts taken in

the erect posi tion . The m,l ~ ,r events ,lll':

• Air rist's
• Fluid sinks
• Kidn c ys drop
• Transverse colon drops
• Small bowel drops
• Bm1sls drop (f~'mall'S: they 1i... laterally when supilll')
• L ower abdomen bulge, and Increases in X-r,ly dt' nsity
• Diaphragm descends {"lusing increased cla rity of lung bases.
The liver and spleen, being fixed , ten d 10 become more vtstble, the remaining
mid and lower abdominal contents It">s so. wbvn the lower abdomen bulge,
under gr,wi ty this reduces the dartty of its rontvn ts owing tn th e crowd ing
togeth~'r of 1'f1;ans a nd the consequent increased dt'ns ily of the Sllft tiSSUI'S.
Depending on the I,ri¢n,ll lll'igh t uf the colon and their nwn decent in the "'TKI
positiun, tIll' kidneys may become more or II'Ss visible.
The erect film, however, I1MY now show flu id level.. (sl'l' Fig. 3_4), which can
be wry helpful in con firming the didgnnsis of obstruct ion and ,1bsn'Ssl's, hut
fluid levels on normal films tend to be \'ery small or invisible. In pcrforatton tlf
the bowel an erect film may confirm a pncumoperuoncum, when g,lS has risen
to the cla ssic suhdiaphrdgm<llic position.
Look al (Fig. 1.1l - NB that this is a different patient from fig . 1.1);

• The 'rercr' marker over T i l

• Th e ut'pt'nden l pos ition of the broast-, c,lusing increased densities over the
right and left upper quadrants. Do not mista ke these for the live r OT splcen -.
their l'llgt"> p.1..... I,ller,1Ily beyond the ronfines ~If the abdomen
• The ~)S in the g,lStriC fundus - typical tlf the erect ptlSition
• Small quantitil'S of trapped f;<l~ between and nutlininloi the gJ~lric rug,ll fold ..
in this p,Hil'nl
• The film is centred high, ",hl,wing , hI' lu ng bases but mis....in~ pa rt (If the
pelvt..
• The position llf the colon. which has dropped u nder gravuy, end bulging of
the lower abdomen ,lntl'riorly, cau..ing the incrl',hl'li u l'nsity in tht' ItlWI'T
third of the abdomen ,UlU nb",:uTinloi till' 'lll<llomy.

20
 The AP erect film conlinued

Gas in fundus of stomach

I

Breast
edges

Gastric
rugal
folds in
body 01
stomach
low lying
transverse
colon

Increased
densityof
lower
odbomen
Faecal
matter in
colon

Fig. 1.9 - This is a rypical normal erec t abdominal radiograph of a female

polien' butthere is insufficient fluid to form Fluid levels.

21
 Calcified structures

look for normal calc ifie d struc tures

Learn to rt'(l ~nil.e the follo w ing structun-s.w hich ca n nnmlJll y calcity and cau se
diagm)<;tic contusion:

Costalcarttlage, may be mistaken fOT ..... Biliar y and Tl'n<11 calculi

Hepatic and spll'nic ralrifiration
Old T8 in lung h..l~'"

Aorta mol y be mista ken for . Aortic anl'UT)"'m (if tortuou s or bent)

lll,rc arteries m,ly be mist,lk l'n for lliac ,ml'urysms (if tortuous or Pt'nt)
Splenic Mll'ry, 'The Ch inl......•
dragon sign', may be mistaken for. Splen tc artery ,1lll'UrySms

l'elvtc phleboliths may N' rrnstaken for .. Urete ric/ bladder calculi

Mesenteric lymph nodes m,ly be

mistaken for . .... Renal yun-tcnc calcuh /sclerotic bone
Il'Sions over spinl' / Silcru m / ilium.
Red fan 'S ,111 round and serious mnSt"ljUl'nn'S for the p.rtu-nt from misdiagnosis
lThly occur from misin tl'rr!\'!ing these normal findings. Don'tlee it happen to .VOlt!

Cos tol l eartltages

On abdominal and ches t X· rays look atthe rib ends. In m,my patients they oflen
ap pear to stop sud denly and nothing is St"l'n (If the cosu! c,lrlil,lges. Keep looking,
however; an d in others a contmuauon of the ribs will cll'dTly ht· seen , Thi s can be
marginal, hl"Wy and detinctive in mak-s.or mort> punctateand cent ral ill fl'lllilles,
and the phenomenon increases with agl-', bUI lIcc,lsiollally can be startlingl y heavy
in the young.
Look ilt (Fig. 1.l0l:

• The multipll' dense fo ci Il W T the uppt.·r and middl l' abdomen. This is cos tal
car lil,l gl' calcifica tion . ..... hich both s imula tes ,1nJ ca n obscure gen uine
assooatcd areas of calcifica tion in tht' underlying l'r~,ln~. such ,1STil or calculi
in till' liver, kidneys or -phen.

Wh.iltn dll ?Obliqul' films, It 'ml~r,l mS{lr CT sca nning m,ly be required lor fu rther
elucidation OTIht· exchrsion of ralculi. Tnmngr,lms ,Ul' X' T,l y films which seb-ct
out slices.lI dif fl'rl'nt II'Vt'! S and blur the b.u-kgrounds.

22
 Calcified structures 1;0<11"'.-1

Artefoc! Ccsrcl cartilage cokifico~on

I I

[ Fig. 1. IO-AProdiogroph 0 ' 0 15·yeor-old womon.

23
 Cclcthed structure s con ~nued

Acrtc

LOllk ,lI IFig_ l .l l l;

• The calci fied aorta OH'r the lumbar spinc. d h 'idi nKat the in ferior body of
L4 into the iliac arteries, w hich cross L5 an d bo th sacral wings. You will
o ften also see interru pted linear calctfira no n in both walls (.f the common
and external ili,l( arteries. whic h may continue dCWSS the true pelvis to the
femoral a rteries in the groins, reprfN.·nli nj!; artertosclerotic cha nges .
• With increasing aj!;e the aorta shows incf(w..ed calcification, JUst like the aortic
knuck le in the chest, and starts to become visible over the aK\' (.f -1(1. Look
carefully o ve r t he lumba r sp ine a re,1 for flecks of parallel or slightly
converging plaques of calcificat ion w hich may be seen: you musl train
yo\Usl'lf to look for th is routi nely on I'very film in nrd er to exclude .10
anl'urysm. Be c,u d ul, however. nnl to mista ke ,I curving osteophyte in an
osteoarthritic spine for the aorta or an ant·urysm.
• In ';(lnw patients the aorta (,10 become tortuous and bent to the left or the
right of the spi ne, but withoutbecoming aneurysmal.
• Look at both calc ified wa lls for loss of p.nallelism before d i agn~ i ng an
aOl'urysffi. as simple tortuous vesselsand ,1nt>urysms can luu k likeeach other.
• Note the age nf ('wry patient carefully. Premature calci fication in the aorta
can be a very significant medical finding - t'_g_ in diabetes or chronic renal
failure- and is nnt always due 10 physiological changes of ageing.

24
 Calcified structures conlinved

Calcified aor ta
I

Point of d ivision Calci~ed L common

of aorta iliac a rtery

fig, 1. I I - Supine APradiograph of a 68-year-old woman.

25
 Ca lcif ied sn ucfures contotwe<i

Pelvi c phlcboliths
l ook .11 (Fig. 1.12):
TIll' true pelvis.There are small round smooth opacities , some of which contain
lucen t (min'S. These an' pblebolnbe. There m,ly b ejust one or 1..... 0 of these 'w in
stones' (IilNa l translation fro m the Creek) or ,I great nu mber of them . In
Ihem'.;l'l\'l~ Ihl'y are usually without clinical slgnificance, bu t tlwy may require
exclusion ,1S ureteric calcu li by an [VU in J'<llil'nts ..... ho pn"il'TI1 with rena! co lic.
and not ('\'ery pelvic op.ld ty is b~' ,m y mean s a urinary tract stone. Rarely thl'Y
molY be part uf a pt'hi c h.u-mang joma.

I
Phlebclnhs
Fig. J. 12 - APview 01the pelvi5 in 0 53-year-old womon.

26
 Ca lcified snuctores """",1Htd

Look at (Fig. 1.13):

• The ~lTIdll of'ilcily in the Ltrue pelvis: r hld lt.lith or calculus?

Arontn.[ film rp. 2l'l) hoi.. 'ot.'wT,tl rurp..~·" :

• To try 10klCatl' tm.· ptl!oition of tht> kidnl'y" before injection
• ToIOllk fliT calculi
• Tot'\c1 uJl' In aort ic d nl'ury~ m - compres-lon hy J light belt is otten applied
acrose. tht- Iow er abdomen Juring IVU." hUI not in renal colic, oIhl'T acute
abd('rnt>n,>, postoperative ~IJt~ or Irauma. The pUTpost' is to prevent
in.ldwrtl'llt mmpreo-ion ulan aneurysm
• To dt'Olt.ru.trdlt' ,IllY incidt'l\tdlfinJin~
• Tod'lt'd. the Tadiovaphic and pn..."\"!t.'Ioingquality prilll" to tlwocontra-.t injt'\:tillfl
and t.Jking 01. turtht'f film..
• To b.j,;, for t"\idl'OCt' of meta..td~ in ..uspected malign.tncy.

27
Calcified strud\J res rotItintoed

fig . I.' 3 - This is Ifte supineAPradiograph ofa 4.>yeor-old mole who piesented
with suspected Lrenol colic. Urologists refer 10 such radiographs cs 'KU8' films,
for Kidneys, Urelers ondBIodder. Other names irdxie 'scour' films and'PRELIM'
films, but thecorrect rodiogicallefm is a 'CONTROl' film. Th is means on X-roy
token 10 cssess the potient before ony controst medivm hosbeen given.

28
 Cckilied structures t;OtlImw<I

Fig. I. 14- Same parient Following theiniection of con/rosl. Nore how the left
ureter has bypassedthe pelvicopacity, which is now shownnot to be a colculus
bvtaphlebolith. The cause of the patient's pain was at a much higherlevel. t.e.
the left pelviureteric junction, which is narrowed and causing dilatation
{trydrorepnrosis} 01 theleftrenal pelvis.

29
 Calcified structures COfI"n..-i

Splenic artery

The splenic artery may only be intermittently calcified , the di'loCOntinuity

making il mort' difficult 10 identify its true nature than in Figure 1.15. Partial
~plenic arterial calcification musl not be misinterpreted as a splenic arterv
anl'Urysm.
Do not mistake it for n'MI artery calcific,lliun: this may of course coens t and
will often be present bilaterally, but usually only the splemc artery shows ..uch a
deg ree of tortuc....ity a" it wend" its way towa rds the spl enic hilum. Heavy
un'rlying costal cartil'lg\' calcification (Fig. 1.15) m,l y make it difficult to isolate
the splenic arterial calrlfiration.

30
 Calcifi ed structures conlinwod

Fig ' ./5 - C4kifiecJ splenic artery This is the left upper quadrant af a l8·yeaf.
old woman. No/e /he serpiginous paralle~wolled calcified lesion intheleft Rank,
resembling 0 'iumping jack' firework or 'Chinese dragon' extending towards /he
hilum of /he spleen. This is the splenic ortery.

31
 Calci fied structures continued

Calcified lymph nodes

Look at ( Fi ~. \.16):

• The inciden tal finding of a collection of granular opacities in the flanks

• The pa rtially coalescent cluster of opacities ove r the L3/ 4/ 5 lumbar sp ine
levels
• Some furthe r small opacities in the epigastrium.

These are calcified lymph nodes. Usually the p<1lient is asymptomatic in regard to
these. Lying in the mesentery they tend to be quite mobile and show dramatic
changes in posi tion from film to film. Con versely, an apparently sclerotic lesion
in a lumbar vertebra can be shown by an erect or slightly rotated oblique film to
be mobile an d due 10an overlying calcified lymph node . Always remember that
on an X-ray you aft' ll)\,king ,1t three-dimensional structures lying on top of each
other shown in only two dimensions. Calcified mesente ric lymph nodes are often
attributed 10 previous ingesnon of T6 bacilli to the gut , which han- been halted
at the regional lymph no...Jes. On occasion they will require 10 be excluded ,1
n-nal or ureteric calculi, and can be a real diagnostic nuisance,
NB Calcified rdrol'l'rillHlm{ lymph nodes, or such nodes opacified by con trast
medium at lymp hogrilp hy, may also overlie the spine but show less relative
motion, being wry posterior. Calcified nudes r.....[uire to bt' differentiated from
calculi and calcification in underlying organs righ t alongside the sp inl' or iliac
vessels.

32
 Calcified structures ron hnued

F'9. I .' 6 - This is a supine APabdominal radiograph of 0 45-year-old mole

Xroyed for obdominal poin.

33
 Decubitus films

A word about decubitus film~ (Fig_ 3 .9)

• The Latin word dl'CI4f!itl4s comes from the Latin dt'Cl4mfttTt: 'to lie down '.like~
Roman pat r ician lyin~ on lus side eating at a banquet , and mean~ with the
pa tient lying on his left or right side, Ib puTJ'l~t" is 10 obta in further
informa tion, such as confirma tion I,f a "mall amoun t of free ga!', or to
demonstrate fluid levels in a panent too ill to be sat up. A horizontal en",...
table beam is used rather tha n the us ua l vertica l bea m fro m overhead for
"urine films.
• Such films require wry close and careful interpretation and should not boo
taken blindly without a wry clea r ide,l of what is beini'i sou ght, usually in
r on pm rt ion with thl' radiologi "l, or ,IS <1 reasonable alternative toan erect
view for the radiogrJpher. Such films, however, ma y be w ry valuable and
clmc h tht, d iagno" is - if :; or 10 minutes MI' spe nt with the patient ill the
J ppmprid te pt~i tioll to allow .:my free ga~ 10 track up to the flank. If you take
it too ea rly yllU ma;.-miss the gas, as Ihto a mo un t ts so metimes wry small
• Decu bitus films can he idenrified by fluid Il,\·t·l.-. l:-ing potrallel to the klfigaTh
of the body, as opposed 10 al righl-a nglt"S to It o n conventional erect films (see
film of the screeum on p. 7 1). ~· an-al..... used routinely d uri ng«lO\'entionai
bartumenema exa minations, and todemonstrate free pleural fluid in the cht-st.
c.g.to differentiate a 'subpu tmora ry' effu..ion fmm a raised hemidiaphragm
and 10optlmilt,thl' view of the uppermost lung bases in patients wh o cannot
inspire fully.

N il A 'rig ht decubitus' means the patient i!' lying with his right sidl' down. A 'lett
decubitus" means the ~'l,1 lien t is lyin g with his left side down.

For technical reasorrs decubitus films lend to clime out wry dark (i.e. over
exptl'!llod) and frequently require bright lig hts behind them III allow them to be
..tudied properl y
The y a ll' best shJ n-d with , and interpreted by the radiologist at thl' timr they
aTl' faUn . Getting a report of a perforation (whic h you have mis~) the next da ~'
when the pati ent i.. dead is too late.
 Cater 2

Solid organs

• like ft't't and noses, IiVl' r.. ro me in differen t ~ hapt.'S and SiZl'S. J U ~I as ,1 liver
m.ly .lppt'.u to be significantly enlarged clinicall y by palpation . it Ol d y also
11Il,k enlarged on an abdominal X-r,ly when in fact neither is the case, and
such aeessrnent is often suhjl'... tive.
• Asaln'ddy ml'nlionoo,lin'("S pushed down by lun~s rhronkally overinflated
by chronic obs tructive pu lmouary diSt',l'iot' , or hdving an alldlomica lly more
t'\ lensiw right lobt, (set;> Fig !i.l'lt can both create th is illusion, and these
film must be remembe red . CllIlVt'fSl.'ly, true ht'patumeg,lly mus t be suspected
when there is evidence {If displacement of adjacent o rg,lnS or, i1S d rough
~uidl" when 1I'll' lengt h (If the liver exceeds arou nd 16 em from the dpt'\ (If
the right hernidiaph ragrn in th e pa rils,lgi ttal pla ne. b u t clinica l and
radiological finding-, may not concu r,
• Liver I'nldrgl'nwnt is of WUf>;l' a very mm-~f".'Cific sign. and serves only as a
reason for Idunf hing furlhl'r i n \'l'sligati o n~ of both hwr function lin d imaging
- usudlly ultrasound to l>t.ogin with.

35
 Big liver conh" ued

Tip of liver leh kidney silting high

Fig_ 2. I - Abdominal rodiogroph of0 6B.yeor-old womon with 0 large palpable

mOSl in the Rside ortheabdomen.

Look Jt ( Fi~. 2.1):

• The hU~l' md~~ in the R side of the abdomen reaching to the lewl of the iliac
C"-'!>I

• 11k' absence of pit in the R side of the abdomen which has been dbpldn...:!
• Tnt' increased densitv of the R slde (If the abdomen
• Tnt' rou nded contigu ration Il f the lower edge of tilt' mass
• Tht' l'n tin- margi n of the norma l R kid nt'y remaining c1t'olrly preserved tty ib
sur n,un"li ng foil, indicati ng that the mass is not renal
• Th e R ma rke r confi rming this is wnsislt'nl wi th the liver
• The left kidrll'y sitting high tu pper m.l r~in n 11.

36
 Big liver cOtl,inV<KJ

This is limss hl·fl<lh)ml~.,ly. (K'(",ISillO,llIy elevation of the R hemidiaphragm or

downward displ,l(vn1l'nt of the R kidney <II\' other signs to look for on chest and
abdominal films. The high ll'ft kidney ( d USt'S spurious a ppa rent downward
displacement of the left one.
Point to ponder: in children the normalliver takes up a dis proportionate
amount of SP.lCt' compared with the adult.

liver enlargement

The main Cd U-.es are:

~l.ilign.tnt ~1<'td ..Ll,*'S, hepatoma, chotangiocamnoma
~letabolic "'ord~t' di'ot'd'it'!'o Glywgl'n, amyloid , fat
InfLJ.mmatory Ht'p.ltitis. <lbSCl.'S"l'S, parasue, 1'Ic.
CiJThoo;is f...lrl~·
suges
V.lSCULn Heart failure. pencarditi..
Hat>m.ltological ~l yl'l"fit>n'Si<;. leukaemia

Small liver
TIlt.' liver may look 10 be on the small side and yet be normal anatomically and
tunetitlllilllv, e.g. in a small individual, and declaring a liver to be pathnk~cally
Wunken from a pl.lin abdominal X-ray to, MI normally attempted .
Asecondary effect uf shrinkage tlf the liver, however, may be that a loop of
rolon - or. It...... frequt·ntly. small bowl'! - may slip above it and become visible
directlv beneath the right ht'midiaphraf;TTl Isee Colonic intt'f'JXlSititm. Fig. -1.5).
Tht.<appt'aranct't'f such aloop dol'Snot, ht'Wl'Wf, pnwe that the hver has reduced
in size, as this phenomenon m.ly occur in an othl'rv..isc normal individual, It is
also more likdy to be seen in patit'nls with large thoracic outlets (COPD). or
postopt'Taliwly when tbe ..ul);l...m has pu..hed the ViSCt'J"d aside 10gel at something
else.
The usual cause for shrinkage (If the liver is the late stage of cirrhosis, this
itsdfha\'ing a number uf ("lUSt-'S, t·.g.:

• Alcohol
• Hefldtihs
• Drugs
• Obstruction.

37
 Small liver conlinued

Coexisting enla rg emen t of the s pleen m,ly occ ur, with associated po rtal
hypertension.

Big spleen
Frequently the spleen cannot be see n on ,111 abd ominal X· ray. Wh~n enlarged
(> l 5<::m ), ,lS with other int ra-abdominal masses , this is detected by an increa se in
size and dl'nsity, and by displ.lO.'nwnt of .ld~lrt'nl structures. A norma l -pteen
can indentthe h-lt kidnt'y, causin g a 'splenic hump' just below tht' point of cont act
(which must not he mistaken for a trot' renal swd ling),an d sm,11I ,1a.:I'Ssory sp lt"'ns
can someti me, be presen t.
NBQ XilSiolMlly d f'<'til'nt will h.1W11\1 splt"' n, dueeither to con genita l absence
or surgical1"l.'mm '.11.
Spll'1l0ml'g,lly can, however, be enormous. t'Sperially when the patient com es
late In medical attention. This finding, like hl·PJ.tumef;i1ly, is nun-specific and
has ma ny C,l USt.'S.
Look for (Fig. 2.21:

• A soft tis~ut' mass eXlending downwards and medially from the left u pper
qua dranl
• Elevation of the lett hernidla ph ragrn
• Media l displ.rcement (If the stomach
• Downward . Hsplacement of the Id l kidnt'y
• Inferior di splacement o f thecolon
• h 'idt'nn' l,f a-sodated liver t'nl.lrgem,,'nt,l nd lymph nud l, t'nl,u genwnt.
N B Occa-koolly the spleen will enIMl;l' st.'II'C tively down the (j) flank l.lll·ral
to the © kidney,

38
 Big spleen t:Otlt.",.-J

Stomach di5 placed to Elevated left

,
right side of abdomen hemidiopnrogm

Spleen

Fig. 2.2 - ~ mis is the film ofon ocJult Iemole who presented with
~Iized ill heol,rand 0 large mon in the leN upper abdomen. Examination
C/ the blood showed changes oIle!"koemio. The man wos shown on uJlrosounJ
b be a croe soJeen. The liver wos noI enlarged. Note the R marker ;U5t visible
0' the rop reFt-~ond corner of the him,
39
 Big spleen conhnued

Causes of spleno megaly

Trauma Ruptureof splt't'n, causing olpf'drt.'lll splt"llumt"gal}'
from a subcapsular haematorna
Infection Acute: Infectiuus mononucleosis
lntective endocarditis
Chronic: TB
Bruct'llosb
IlIV
Molldria
Neoplas m Secondaries from bronchus, breast, gu t. pruSI.llc
Lymp homatous Hod gkins' diSt.',lst'
Non- Hodgkins' dist'd"t'
I I,lI'matolngi cal Leu kaemia
Polycyth,lt'mid
~ln'losdt'n,.,is

Storage disl.mJeN
rurtJl hYJ't'l1elbitlO
Cystic masses
Others
Haemolytic anaemia
Caucher's diSt'ol'>t.'
Polycystic di....aSl'
Hydatid cyst
Developmental cysh
Rheumatoid
Amyloid
Sarcoid
Cottagen vascular diseases

Big kidney,
Nutt' (Fig. 23):

• The bulkv tout SIIl<ltllhly outlined kidnt")'o;

• NI'T1l'\J.l kidneys e... tend from arrm...im.ltt'ly thelower margin of TI2 on the
left to the urf't.·r m.lrgin uf l.J on the right, Of about 3.5 vertebral bodie.... tpfus
di~)
• These kid n ~ extend from the Urpt>f margi n {IfTI2 on the left to the upf't'T
margin t.f 1..1 on tht, right. (If 4.5 vertebral bodh-, (and discs) in this patient.

40
 Big kidneys CDnlt.....d

•
fig. 2.3 - Enlarged kidneys This ;s the film of 0 patient pre5efltir1J::tolly
WIth symp/Oms and signs of 0CIJIe glomerulonephritis with M , and
profein in the urine.

41
 Big kid neys COIIh"..,.d
-
• Kidneys vary in ..in' and shape and the It'llone is usually !io lightly 1.H~l:'T than
the right by up to 1.5 em, although 01 duple kidney Ii.e. one with a double
drainage sy.,.tl'm ) ffidy look abnormajly big but still be hislolugicdlly normal.
• Kidney!oareusuall y 1J.rgl;'!' in men than in women, and each individual kid~·
shou ld ooll\l..rtrLdlly lit> more tha n about 3.5 vertebral bone, long, including
the intervening lumbar discs in a gin-n patient, measured in their long axes.
i.e. from pole to pole inclined towards tho spine. Kid neys over 12 em and
under 9 em aft' usually rega rded .IS pat holog tcally lugl' and small,
respectively Kid neys in young child ren normally 'lppear dbpwJ'llrliolli1tdy
lafl:;t' just as the liver d ot'S.
• Bilaterally enlarged lIT unil,llerall y l'nl,lTgl'd kidneys ffid y be pn'SI'111 with one
normal sizeor shrunkenon the cllntr,ll,l lt'fal side. Enlargemt.'nt of 1',ICh kidnev
TThly ,1\s.O be generalized d ue to global di"t'd"t' or :-.tlmething mort' focal, such
as a cyst tumou r or loc ali zed hyper trophy. So..c alled co mpensatory
hypertrophy of a n'llldining kidnt'y m.1Y abo occur if the other one reases to
function or is removed, but this re.pvn'>t' reduces in the e1dt'rly.
• The importance of detecting Iargt' kid~ is that then> Illdy be tht' potential
for recon .'I)' when Ihisfinding ~a!'..o;ociatt'\l with renal failure, although biopsy
will be required for definitive d ia~nosis, almos t invariably preceded lly
ultrasou nd to belp exclude renal ooserucnon and dSse-;S the parenchyma.
• Converse ly, sma ll kidneys usually reflec t end .....tage renal d i"t'o1'>t.' and an
irreversible stall' , making biopsy somewha t acad emic and putentiallv
hazardous.
• Loo k carefully 10 0 ,It the edges of ttwkidlWYS. whether smoafh, lobulated or
n regulae - important points in differential di,lgnosis.

Causes of bi laleral big kidneys

• Acu te glomerulonephritis
• Diabetic renal diseolse (glomerulo·;clt>n",is)
• Adult polycystic disease
• Acute tubula r necrosis
• Acute cortical necrosis
• Bilateral acute pydonephritis
• Leukae micinfiltration
• Lymphomatous infiltralion

42
 Big kidneys con r",ued

• Amyloid
• StorondJry I'm ,11 d i ~\N' in gout.
• E\(~siw beer drink.i n~ - medical"tudl'nls I'II'J"'" noll'!

Somt uu~ of un ilollt'u l big Idd nt'y

• Acuteobsnuctum
• Acutt.' inf.m1itm : I'\'fldl drtl-ry rcctu..ion, renal win thrombosis
• Acutt.' I'yt.'lllnt-phnli..
• lUdi.ltion rwphrili.;
• Dupk-x s~...ten
• Compl"lbdillry hypt'rtnlphy from contralateral nt'f'hl'\-'ctl>my (If dysfuncti<m
• Rrn.al~.

Small kidn. s
~ing ltwo ~ l>f ..mallk.iJ~'$ may be \~. dlffJruIt or imf'l.... sibk
onpLun filnb(lYoinf; tooverlying f,lt'CIOS ill1o.1 ~s. H,IWel.W. if the J'dtit'flli5 cll'arly
Mn"t'.md not Ill'I di.lI\·5is th..-n- mu-..t be functioninp; M\a11bMJt> SllRk'wfwno. anoJ
OC'Gbion.llly it b vbiblt.'.
gememben The lidnl"p shrink. or dlrophy with age, compcnsatorv
hypt·rtrorhy ma~' nlllllccur III Iht' ddl'fly, and X·ray measurements will d lwa~'5
grve .. :»-25 maf;nificali(lfl. so lhoil X-ray IDt.'a-'iUl'\"ml"Ilb will alwaY'" be Lugt'l"
ttwn Sl1"t"> obtdined lin ultra..o cnd, CT or MRI examinations, fr.r t'U mpil'; IIX'
if'PdT'l"nl Sill' Ilf the kid nt'Ys may also mcrease even moll' afte r i.v. co ntra-,l
oIdmllu.'.tTation fill' I\'Us.

UUW'\ of smolU kidntys

• Chrome glllml·rultl'>Cll·n....is (u.;u.llly biL.lll'rall
• Chronic i.'oChal"mi.l kg. n'fldl drtt-ry SII'f1llSis, drtl'rio~<k'fO'>is)
• Chn:mic pyd orlt'ph rili..
• Rdlu, nt'J'hnlp.llhy
• lniarction
• St'llill' alnlpy
• (ongl'n il.ll hYf'lll'lM.iil (u..uall~· unilatcrall,
 Con g enital renal abnormalitie s

NH Alw ays rem emb er that an unknown pati ent may have o nl y one
fu nclioning kid ney, Thb i!> t"-pt'\"ially important when invt"!>tiRdtin~ trauma: mort"
than one p.l til'nt in medi cal hish,ry has hod his only kidney taken ou t, and kid neys
have a remarkable capacity for ht"l lin~ ,1Ild regen eration.
~ B A patient who is known 10have only one funct ioni ng k id ney And wh o is
pAssing urine Cdnnol be complete ly obstructed. This is somcurnes forgotten by
young doctors requesnng 'urgen t' IVUs for '? obstruction ' when rme kido l'y hac
been removed.

Two importa nt co ng e nital re na l abno rma litie s

Pel vic kidneys

when inVt"Slig.llions fail to demonst rate kidneys in the renal bt>.Js, Olle or more tlf
them is usually found at a lower level in Ih,' pelvl...This is called an ectopic kidney
(Gn't'k ,'k, out of, ttl/JOs, place). Inflamed pd vic kidneys C,lO simulate appendicitis
or gyn,lt'colog ic,ll probte ms. Rem ember: transplanted kidnt')"S mol Y be put into
Iht' pelvis and even a norm,l lly sited Id d nl'y m,ly be invisible.

Horseshoe kidn eys

These C.1I1 som etim es hi' sus pected or di,lgmN;'l.1 on plain films. Tlwy tend 10 lit'
lower than normal and tend to I,Kk the usual medial mclmation relative Itl the
spine .11 their uppt'r poll~. TIll' pathognomonic r,ldiologkal sigo is 10 WI' the
rena l cortices of the lower kid neys crossing the margins of thl' IlSods muscles
medid lly to connect with the etfu-r "idt' , This part of a horseshoe kidney system
is known rlS the ist hmus. The d r,lin,lgI' sys ll'ms in this condition tend 10 be
m..rlrota ted forwards. The isthmu.. may contain euher functioning "I' just fibrou s
tissue.
Look at (Fig. H):

• The cortical margin.. of the kidnt'y .. m~siog the p SO,l S muscle,

• The ,lSSl.lCialt-.J developmental spinal anum,lly ,1IIh(' Ll /4 levelon the ll'ft
and the <,clllit)Sis convex to tht' left.

"
 Coogenital renal cbnoemcbnes conhnued

Renal cortex crossing the pscos muscle

I Fig.24-Hof$eshoekidneys
 Congenital renal abnormalities conbnved

Fig_2.5 - Iiotw~ kidneys Somepotienl following i.v. conlrost confirming

horseshoe Hdneys.

46
 Co ngenilal renal abnor ma lities COrI,in..-:!

\..ol.lk 011 (Fig, 2.51:

• The abnor mal lu"'t'li renal rtlllt":lin~ ~y~ll'm~ llH'rlyin~ the spine a nd the
i'lhmu~
• Ibe IT\dITllt.llt'ti righllidnt'y with itv colltorting ~y!>tt'm fdcing antero-latcr... lly
in!>lt'dd of mt,Ji.111y"

Compliulion!O
HtJf!ol'!;OOt> kidnl'Y~drt' mon- !ow>I.""t'ptiblt'ltJ infection, !otonl' formation ...nd trauma.
TlJto holhmu!o m.JY a1o.tl gt"t in 1l14.' WdY in rdditilOOdPY planning" HtlN.oshtlt,
lidtll'\"S 1J'\oI\' occur in TuTT'll"r's svndn>mt".

RInGI mau e ,
RrNI trId~'ol'S m.JY be ftlund during Iht> inn~ti~h(ln of a pdtimt "';lh UriIldIJ'
troJd !oymptnm..., such d~ haematuria, ur as an incidt"TIldl finding when Iht> p.1lil'lll
~Mng X-rd~'oo It)!" .;onwocht.>r purptl'>l'. e.g. bdckdchE-, but t'\"m d larp' orw m.J~'
lIP Ul\bihko en d Stdnddro. him"A sigmfKdnt M\dl m.JS'" m.JY ht.lWt>\"t>r.

• IX'IVl1 the pt",ilivn t>l tilt.' dnlic1p.ttl,J renal t",Uinl'

• Actu.1Uy d~spl.-.ct-Iht' lid~' mlm which itdn_
• Di.'f'LKt' tI\"t"rl~;ng ga.....contdining Iotlf'!' (I{ bowel
• Cn....!> the mdlme tothe tJppt"'itl' vide.

j-Lning dt'tl"Ctlod d m.J.... Iht> prlm.Jry rt'lIU1ll"llll'llt is Iht'n 10 t'!>tdblbh wht.:"tht'r it

ill 'oll/id or C}...uc. and thiv can usudlly bt.> t'a~ily achwnod with ultrasound. Furtht"l"
urt'lul inspt'ctitln of tht' plain films in the initi.ll phase, however, III Illtlk for ll~"
of pso.ls tlullint'" or buny d~tructitln of pdrt Ilf a vertebra. md)' indicatl'
IN!i~ncy hum thl.' ooh...t" ull"king intn the lung ba_ on dn sbdorrunal X-rdY
may also 1m ceca..ion 1\'\"1',11pulmon.m - meta..la......., a nd ..hould be routine on all
abdomin.al X·rdy"wht'1'l.'lht""l' are vi..ible, althnugh d full rbc...1 X-ray will al",a dy
be indicalt'ti.
The nextta..l i.. ~Idging with CT 1,lthl' ma-s. MRI etc.

47
Renol moues conlirwed

Fig 2.6 - CIoHHlp view from obdominol him of [Honk in 0 56-year-old mole
presenting with backache.
 Renol messes COI'Ih nued

This p..ltil'nt lR);_ 2.f1l initi,llly had hb lumb ar sp ine and abdomen x-rayed to
look for a cause fur his bJd,al' hl·. Ap•art from minor dl1\l'nl·r.1tive change no
~I abnllnn.llity was found, but can- lu i i"-~f"'("tion of the film showed the
edge of a large In.l'" in the It'll flank w hich was cle.uly 100 big 10 rep resen t part
of a nOl11lJJ kidney. An ultra ...>U nd scan ronfirmed a solid ma"s arising from tht'
Il'tt kidl'lt'~·_ On billf'!"Y this w a.. found to be a nm.al carcinoma.
\I oral: Do nol confine youl"'O(' lf to th e area o f p rimuy interest alone e n an X-r.y
film. bullook ••• 11 of it. Alw.y be ready for the unespected Incidental finding.

A word about 'd isplaci ng mosses'

{ll\~y an .bnormal ma".. can an.... anywtwn> .00 it'> ~t'1lt"I"al effect will be
eeseee. i.e. to produce a dt'll'>l;' area with di<,plaCl'fTlt'llt of bowel loop-, around
It. Sophi~icatl"d in\·~ligdlion .. y,'ill boo' nt'(l"'!oSd.~ · In l"'!olablish the evact cause
1Wtn.'>OtJI'IJ. CT, 'IRI, barium rid. ShoulJ the ma .." It~f contain a lot of gas thi..
",'in usually indicate part ot the bowel il....·1f te.g. \'ulvulusl o r f"'Thdp!io an al>sce....
1J.t't" Fip ·U3 and -un The den..ily ul a mas .. may also be inrn"a~ by the
f'l'l'Sl'N" at caldficdtion y,'ithin II.

49
 Pelvic masses

The urinary b ladder

In p ractice tht' most common reason for findin ~ a la rgl' 1J1d"~ tin X-ray in the
pelvis i" a full bladder (Fig, l.l), and ther e arl' a number of rt'.Nlns for th is:

1. Paucnts often han' to wait to be brought to X-ray and their t"ran"it molY be
del.wed .
2. Further w,liling pt.·n ods <11\' com mon in busy X-ray dt' f...art mcnes.
1 Somt' pa lit'nts will have genuine outflow obstruc tion, e.g . .lUI.' to p rustatic
d i....-ase, ,mJ be unable til empt y Iht'ir bladders compll'ldy. Some patients
who com,' back fOT KUlJ films and renal u ltrasound are spt'Cifically asked 10
attend with a full bladder.

In s''l' ldng lhe bladder, look for:

• A smoo th rounded or tran'!>wl"ol'ly orientated oval m,h'!> of uniform dl'nsily in
tilt' pelvis. lts outline , when visible, is d ue 10 perivesical fat (st.'I;' Fig. 1.1)
• Upward di" pLll'emen t tlf small bowl'! loops. which ,1I't ' h\'d y mobi le and can
(,.lsily be shi fted com pletely {lui of the pelvis
• hn>o;sin' indentations in add ilion Itl the normal ones ("igmt.id ,lOti uterus!
ca used by p'llhologicdlly l'nl'll);l-'d masses (('.g. fihJ'tlids) (' T faeca l overload.

Common caus es of p elvic mass es

• I'h ysinlog icall y full bladd..r: ma ll' or fl'mall'
• I'dihologicrl ily full blad d er indica ting outflow obs truction. ('.g. prostate in an
"dull male or a blocked catheter in a female
• Bulky u terus (pn'gn,lncy) -111I,k fur fCl,d P.lfts' Did you check tlu- LMl' (1,1.,\
menstrual ~ritJoJ l bt>tnn' TetJul'Sting this film?
The majority of slgntfkant abnormal pelvic ma sses occur in females, includi ng:
• Leuun yomas - fibroid s, often calcified
• Ovarian cysts - can be the Sill' of a footba ll
• Ova n an tumours (be nig n or ma lign.ml l
• Pelvic infla mmatory d1>eo1 >;('/,Ibscl>o;""'"
• Haemalnmetra (blood collect ion in uterus !
• End umetrtosis
• Haema toc olpos (blood collection behin d imperforate hymt·n l
• Dermoids, containing f'll, teeth, hair.

50
 Pelvic mosses conIi....d

Fig. 2.7 - AP pelvis: /VU examination, bladder area. Look at /he effed of a
ItUge pelvic mou severely compressing the bladder From above. This was on
00'0I'i0n cyst. It is alsoporliolly obslrvcting baf., ureret-s.

x on-gynaecologi cal
• Al;>:;(t~ from dpr'lmJix, diverticula, lvm p hoc oete (rO"lnpt'rJliwlyl
• Pelvic kiJnt·y Icnn~t'TlitJ1)
• Renal transplant.

51
 Re 'toneol masses

These usually ONUTt' the flSIliIS muscle on the affected side OT show a displaced
fat lim' convex and beyond the m<lll;insof the anticipated position I,f the F>SOd~
muscle. They may show displarcment of tht' kidneys (see Fig. 2.Hl Of aorta. ,lfi'
oft...n maligna nt, e.g. Iymph,ldenop.lthy, and n,!uin' furt her investigation.
Do not mistake slight cunn-xily of the normally stratght pso;.liIS m,ITgins for
pathology. These can hYP'-'rtmrhy in \"l'ry athletic individuals, just like the
gastrocnt'mius muscles. Such Individuals lTh1y also shuw incipient degenerative
cha nges in the hips in early adult life and medial deviation of the uren-rs on an
IVU - signs to seek in confirmation,
Look at lFig. 2,K):

• Theabsence(,f the normally ptlsitltlllN fN>.h eJgt' on the ll'ft sideand (lmWl
tll.1SS more lateral tn it

• Normal spit...·n
• Upward and lateral displacement of thl' left kidnl' y,

This is TI'lwper1h>lwallymphadt>n0l'alhy, JUl' to lvmphoma.

52
r Retroperifoneal mo sses cot1tittUed

Fig, 2,8- This is on lVU Mm showing renal excrejonina young man who presented
with a moss in the neck, weight lossond backache.

53
 Acute pancreatitis

There art' no plai n film signs that co nfi rm or ex clu de ac u te pancreatitis. The
d ia~ nusis is a clinic al one supported by high seru m amylase levels. Ches t and
abdominal films will, however, usua lly hJ W been taken on admission wh ile the
dia gnosis is being sorted out. Il1ldging th is condition and its complications is a
jo b for ultrasound or CT, but underlying causes and seconda ry ef fects molY
occdsilln,l lly be tderuified.
l ook for:

• Call-tone, Imay Ot' a pn..Ji!'posing fdctllr)

• Calcification in the pancw,ls (chronic p.1l1cmltilis nMy be cumpllcated lIy
MUT",nt bouts of acute pancreatitis ). Occasfonally ,1 tumour cont.lining
calcificanon moly precipitate pancreat itis
• Pleural dfusiun s, b.1~1 dtt'lt'l:t,lSis, diaphragmatic elevation
• Sign s of secondary Ileus
• R,m'ly in severe dtsease gas bubbles lll,l Y apf"t'a r in the panrn.'ols as abscess
formation supt-'rv ent'S
• Retnrperitoneal /;<ls l pneumoperitnneurn - r,ll't'ly and usually in severedisease,
May be confused wi th perforation
• Ascitic tluid
• Bone infarct s t' .g. head of fem ur (w ry rare ).

54
 - Cater 3

Hollow organs

The stomach

• Abnormallv l.u ge stze (If the gastric outline

• Exce- sfve q u,l1ltity of st'mj o.:l i~l~ lt-d fpod in the stomach
• Smallqua ntitv of ~dS in the ..mall bowel.

Look at ( fi~. 12 ):

• Thetwo fluid le\'t'ls, that on the left representing the g.l.,tric fundu.. and Iholt
lin the right the d uoden um - the so-called 'dou ble-bubble sign'.
• Theactual levelot obstruction b in the duodenum, C,lU....-d by scdrring and
~It'm~is frum ulcer di ....·,lSl;·.

Causes of gastric outflowobstruction

• Pepuc ulcer J in dis tal "tomarh /duudt,t1um with scarring
iSt',lSt'

• Ca stnccam noma in antru m

• Lymphoma
• Gastritis
• Crohn's diSl.'dSt' (stomach or d uod enum )

• TIl
• lmpacted fllrt.·ign bodle,
• Bt.>ZOdT Ifurball, wgl·tahlt' m,llh'r)
• ~l t·ld SI.l ses .

55
 The stomac h confj,,,...J

Calcified Extensive semi-digested load e nd gos in

lymph nodes the stomach Iilling ml,lch of the abdomen

Fig. 3. I -A 5J-yeor-<Jld mon with 0 2.year history of dyspepsia wha presen,ed

with l,Ipper abdominaldis/emion, 0 succussion splosh ond vomiting. This wos
due to outflow obs/ruction ond retention of food residue and Ruid. A 'bezoar'
looks similar - re'oinedvegetable maffer (phytobezoar), or hair in the stomach
(trichobezoaror hoirball, morecommon in animals) .

56
I The stomach eorohr,,-I

Mo5S of food in stomach Gastric fundus

Duodenal bulb Fluid level

Fig. 3.2- Same patient: erectview.

Gastric neoplasms
Sometimes tumours m,ly be visible in the fundus of the stomach un abdominal
films and chest X-rays, this bein~ an (II:C<1SiOn,11 presentation of ~dslri( carcinoma .
Such an ,lpf'l'dr,mCI' must, however, be interpreted with gIVolI (dUlion,,l'" a
ph~"'ii\ll~ically contracted stomach canlook \ 'I'ry simila r, the left lobe of a normal
liver canindent the stomach here, and posroperanvely fundophcanun prOCNUrl'S
prlldlK't' fill ing detects ml.J.iallythai sim ulate abnormal masses.In the appropria te
clinical seumg hwight loss, anaemia. dy!>pt'p.;,idl, hO\\'l'WT, pollients ca using
corcem 0\'('( this ,1ppe,U,lnet> should bot- inn...tigalt'l.l .

57
 Distended small bowel

Small bowel pathology usua lly manifes ts itself on plain X-rays by abnormal
accumulatio ns of gas a nd fluid, due to either functional (i.e. ileus) or truly
mechanical obstruction. The main problem lies initially in trying to differentiate
sma ll bowel frnrn large bowel.
Once the sma ll bowl'! starts to dilate the sma ll irrt>gular pockets of g,h that
may be seen nor mally increase ,1IId coalesce, so that eventually the interior of the
distended loops becomes com pletely outlined in continuity where the lumen is
not occu pied by fluid and com plete mucosal folds appt'ar.
Remembe r:

• The colon is peripheral and containsfaeces and gas

• The small bow el is central an d contains fluid and gas
• TIle more d istal the obstruction, tilt' mort' loops you will SCI'
• TIll' longer the du ration of the obstruction, the bigger the fluid levels
• Fluid levels can only be seen on erect or decubitus films, and small fluid levels
can occur nor mally
• It is not lleH'Ss,l ry to be obstructed to have fluid lewis.
The stan dard series of films in the acute situation is a minimu m of ,1 supine
abdo men and an erect chest X-r,ly. Exper ienced radiologists claim to make do
with these dione, but most mortals art' reass ured by an erect abdomen ,1S well.
NB Th e entire abdome n shou ld be vis ualized, idea lly on both th e supine
and erect film s but certainly on the supine film s from the top of the diap hrag m
to the hernial orifices in the groi ns, as these may be the site of an obs truct ion in
an inguinal hern ia. But rememb er that the pre sence of a hernia doe s not prov e it
is causing an ob struction. Two fil ms may be requi red in each position to show
the entire abdomen.
Look at (Fig. 3.3):

• The multip le centrally placed loops of bowel distend ed with gas

• The outlines of folds crossing the entire lumen in places
• The absence of ,lny flu id lewis.

[
58
 Distended sma ll bowe l conh"ued

DiSlended loops of small bowel Stomach

Fig. 3.3 - Thisis the supine abdominal radiograph 0/ a patient presenting w ith
abdominal pain, distension, nausea and vomiting_Note absence 0/ fluidlevels.

59
 Distended small bowel conlin..-J

GoslJic flu id level

I

Small bowel
fluid level

Fig. 3..4 _ This is thesome patient in the erect position. Nore new thepresence of
fluid levels.

60
 Diste nded small bowe l eOll,illu«l

Thi~ (HI-':. 3.4) is tht' d,lssic appt'Mance of a sma ll bowel obstruction. The
rrlativelv small number of IllI'f'S indicates a mid small bowel rather than .1 distal
"lI1.l11 bowel obstruction. The cause was adhesions from prev ious surgt'ry so me
~"t'.ars
before.
~B In order 10 demonstrate fluid levels you need fluid, llwrly ing g,lS and a
horizontal beam erect or decubitus film. Withoul the g,b you won't see lht' fluid!
Although oosuucuon and pertoratton usually pTl'St'nt S\'p.udtt'lyand clinically
JlIil'T\'ntly, alwayscheck til make sun' the patient has not sustained a pt.'rforation
as a complication of an obstruction. This is ,1 ra n - but import.mt even t.
SB The differential dcgnosts of small bowel obstructio n includes poualytic
dftl, and it may be hard to differentiate between the two un r,ldinlogical grounds.
ThI.'c1inical context is usually crucially helpful, ('.g. immediatelv postl1pl' r,l!iwly.
Re member: Hoth gener.llizl'd and Incalilt'd ileus molY occur, t'_g theletter
\lith 'sentinel loops' ad~1Cl'nl to an appt'lldh .I1:'sn'Ss.

Cause, of small bowe l obsuucuon

• Pustopt'l"<1livt' adhesions (up ItlllO'; of cases in western countries)
• lreernal strangula tion of bowel Iband or internal hernial
• htl'm,ll hernia re.g. inguinill)
• Lymphoma
• Crohn's disease
• lntrnluminaltumuur
• Gallslone ileus (set' p,l/l;e 041
• InlussuSCl'plilm - usu.llly t"hildn'n; in .ldulb ofte n as!>l.JC1dlt'd with a tumou r.
Tends tl' begin in theileum
• Congt'nit,ll arresias - newborns.
Lpdate: RI'O.'ntly spiral cr scanning of the abdomen hils ..hown itself 1,1 be a
\'ery elegant way of dl'll1tllJ"tratin~ peritonea! ad hesions causing obstruction,
but tilt' actual cause of 010.. 1"mall bowel obstructions is notap pa re nt from plain
films alone.
Confound ing factor: An inflamed or obstructed colon m,ly contain fluid, in
addition 10 the pr t'Sl'nn' of small bowel fluid levels. Diffprl'n tiatin~ loops of
~m.tll bowel frurn large bowel can then be eXn'rtionally difficult.

61
 Distended smell bowel conhn\.Oed

A b it of epidemio logy
As bas already been stated, in the developed world, most small bowl'! intt'St:inaI
obstruction is CdUSl"IJ by adhesions. In place, such as Africa, however, ~
are by far the mosllikrly cause, as n>latiwly lillie in the way of pn>\iu\ls sUIKny
"ill haw been earned out to CdUSt;' adhesions.

Voscular cotcsn opbee

A mesenteric artery thrombos is or embolism is ,I cnticalevent pn'Sl'n ting as an
ac ute abd om en . R,IJ iolo gk aUy the signs ,m.' those of ileus in the bowel. moving
Oil 10 Infarction and pt""sibly gas formation in its walls. The clinical sentng, e.g.
atrial fibrillation, previous myoca rdia l infarct ion etc., is im po rtant in suspecting
this dtagnosts. Occdsion dlly mesentenc vein rhrornbosts "ill be the underlying
cause as~lCidted with pancreatic carcinoma

Ileus

Combined small and Large bowel dilatation molY form the eta ....sic radiologica1
signs of paralytic ileus which, as stated. may be hard to differentiate from
obstrucnon.

Causes
• Postoperativ e - after h.mdhng of the gu t
• Hypokalecnua
• Drugs, e.g, L-dOP.l
• lnrra-ebdommal <;l'r-is(pe ritonitis)
• Bowel tntarcnon
• Trauma
• Reflex ileus from acute abdomen Irenal colic. Il;'.lkingaorta).

62
 Di stended small bowe l conr',,""'"

Gallstone ileus (0 specio l lor m 01obstruction)

Ihiscondltion b !\.'U~nilrd by ,lbnnllll.lllydistended gut and gas in an abnormal

location, i .e. th e bili,uy tract . It b in f,Kt a misnomer, bt'ing due to ge nuine
mechankal inte, tin.ll obstruction, CdW~>J by a 1.I1):;t' galbtlmt' impdcting in tht,
~t, u~ually at the terminal ileum wht'lV the bowel is rldmw.·""l. This occurs
u~ually after fj~luld formation t.... twee n tht' gallbladder and the duodenum. It b

QD('of tJw CdU~ uf intt">tilldl obstruction wht'!\.· the actual CdU~> lTldy be infl"fl'l'\i.
l'nJLI!VIl.1Sl'd dnd untl\.'dl.>J it earn..... d high mortality
Lonk fUT iRg. 35 ):

• \ lultlplt' dildll>J luop!> of ~1T\J1l bowel. i.e. o.'ntrdlly placed loops where tht'
folds go right ~ I"'" lumen. Tht' colon l\"Il\oIilb normal. This indical~
'>U'IaO btlY..l'I t~tructiun .
• The number til di..tended ItJl'p": the more there are, the more di~tdl the

•
"""""""" .
Ga..~ in thebiliary tn..•. In thi... p..llil'llt tht't'I1til\' bill'duct i"OlItliooJand diloltt'\!.
Gob is ~I in the lumen tM tht' ~1IhL1dd("l". However, largt' ~..able
qwntitit">of ga~ "ill notalwa)"s lit' rn_nt dnd onl)" in about a third otcase,
will the bile duct be lully di~p1.Jyl'd _
• The gdll..tore. M<P.>l commonly thi .. i.. nol seen. but mAy be located in tht-
right iliac fO"Sd or uver tht' sacrum. It fn.qut'ntly consists of radiolucent
~erol "ith onl)' a thin cakifed rim , ITldking it hard to see, but in around
til panents II ts ,"h.ihlt'. M tt~ t l*""tructing stones are over I inch 125 em)
in diarJlt'tt"l", and may in fact be Iargl'l" than tht'y Iool if moll.' choIt">tt'fOl ha~
bt'\'!I dl'pt""itt'd bt-yond the cdkirwJ rim. If th.- p.!tit'fll was pmiou.Jy known
to havehad a gdll~ttme in the gallbladder, look to see if it has ~ont' hum thdt
jccenon.
' B\"0 ~tOl\t' was \'i~ibll' in Ihi~ pdtil-nl.

UU'>I'S of ga~ in th e biliary tree

• Pl't'\itJU~ biliary SU~t'l")·. e.g. Whipple's operation or anastomoses III rhe gut
• lnstrumen tation, t'_g_"Rep / "phinCh'fillllmy
• Fistula forrrunon, t'.g. ~ll~ltlm' ileu-,
• Posterior f"..rfl.ratilm lli In ulc•-r
• Mali,l:n.lOt ~rll,',IJ to th.' bile du..t
• EmphY"t'Tll.llllU" chn lt"'Y~liti~ (diJblotic-.1
• IAl\ sphincter (rhy~il>lo~ir,llJ.

63
Distended sma ll bowel con,inued

Gas outlining Gas in Solid faeces Dilated small

gall b10dder bile duct in colon bowel

Fig. 3.5 _ GallsloM ileus This is a supine AP abdominal X-ray of a 55·yeor<JIcJ

woman with a history af right upperquadrant pain, who now presents with more
severe pain, fever, nauseaand vomiting. The X-ray shows distended smallbowel
and gasin the bile ducts. You ca n also see gas in thegallbladder.
 Distended large bowel

Figures lb and 3.7 show a dbl'l ll'l rge bowel obstruction caused by a carci noma
of the descending colon in an elderly woman who presented late w ith rectal
bkoNing, weight loss and, Idtll'r1y, increasin g swelling of th e a bdomen.
Colonic obs truction can ,1SSUrnt' a nu mber of ,1 ppt'Jrdnces, depending on the
position of the obstruction and whether or notthe ikocacc al valve is competent.
If it is.the caecum, being the mos t distensible part of the l,u KI' bowel, will distend,
but if notthl' bark-pressure ....;11 be transmitted th rough the valv e into the small
00...1'1. and that too will distend, as in it small bowel obs truc tio n, but wi thout
caecal distl'IlSion.
Dtsenslon of bo th of these pa rts of the bowel together can of cou rse occur
withoul obstruction, owing to ill'us, and Isolated co lonic diste nsion ('colonic
p5l!lldl>"Obstruction') may also occur assodated wtth medical conditions such ol~
Ml(myocard ial infarrtitlll). and thl' rad iologist may be as ked to exclude organic
obstrucuon by run ning in some contras t medium retrog radely Th e critical
diameter f(lrthecaecum is 9 em. beyond w hich it is in greet da nger of perforation.
Look for:

• DiI,lIt'<J loops (>ocm)

• MJrked distension of th e caecum
• Gmeral pt'riphl'ral position of bowl'!
• Several incom ple te ha ustra l folds, typ tcal of the colon, and a few complete
ont'S- normal variation!
• Fluid faeces (III the Il'ft (erect film>, indicating colonic malfunction
• Involvement dow n to the level of the descending colon
• Alack ofdistensionof the small rowel, indic ating d competent Ileocaecal valve.
1\B Most colonic obstructions in the UK art.' caused by tumours (u p to f{I ~,),
but in SOIllI' other countries torsion of the bowel (volvulus) is the commonest
rau-e.

65
 Distended large bowel COtl"nwd

Very distended Distended low lying

caecum Iransverse coloo

Fig. 3.6 -SupineAPlilm of abdomen. Female potienlaged 72, presenting with

severe abdominaldistension. Nate the absence of Ruid levels.

66
 Disjended large bowel «J(lhnued

LOfge fluid level in

oKending colon

Fig. 3.7 - Same potient ~howjng big Fluid levels in theerectposition.

67
 Distended large bow e l conhn.-/

Cause s of large bowel obs tru ctio n

• Carcinomas (unlike the small bowel. where adhesions art:'the most common
cause)
• Diverticular disease
• Volvulus - most commonly sigmoid and caecum (see below! in parts of the
bowel with a long mesentery
• Inflammatory bowel disease te.g. Crohn'st
• Appcndb abscess
• Metas tases
• Lymphoma
• Pelvic masses.
Ca uses of colonic pse u do-obs truc tto n (mdY require contrast study to exclude
tru e obstruction and intervention to decompress caecum)

• Ml (with pulmonary oedema)

• Pneumonia
• Mvxoedema.

Abdom inal hernia s

Apart from being an intl'resting incidental finding, the prt'St'ncl' of external hernias
is important because thl'y m,ly be the site of intestinal obstruction. From the
diagnostic radiological po int of view the most sig n ificant application of this
knowledge lit'Sin ensuring that when a patient presents with intes tinal obstruction
the inguinal and femoral regions arc clearly demonstrated on the films - prt'fe r,lbly
ill both the erect and the supine positions.
If an obese patient has a strangulated hern ia in the region of the groin this
may be d good way to help confirm it.
NB Th e p resence of a hern ia in the context o f intestina l obstru ction dol'S not
p rove that th e he rnia is the cause of th e obst ruct ion. However, if th ere is
di rection al con tinu ity of a loop of bowel straigh t toward s a cu t-off segment of
gut in a hernia, for example, tru e cause an d effect are most likely, Rem ember, if
a h erni ated loop o f b owel does not con tain gas it will not be vis ible.

6'
 Abd ominal hernias eonl,nued

Scrotal hernias

Appearance of hernias in th e groin

look for:

• Loops o( gas-fillt>d bowel e\tl'nding below the level Ilf the inguinalhgaments
on both sides
• Cuntinuityof I hl~ loops ",vith another loop in the true pelvis
• Enlargement of the scrotum 10 accommodate these loops (auscultation of the
scrotum may render bow l'! sounds audible).

Fig. 3.8 - Scrotal hernias in 0 5Q.yoor-old monoThe X-fOY shows bilo'eral hernia
foI"mo,iOll in !he groin, extending inta!he scrotum. This was on incidental finding
and mepollem was nolobs/fue,ed 01 the lime.

69
 Abdominal he rn io~ con'i"...d

ulok <II (Fig.H):

• The massiw scrotum containing mu ltip le f,a../ liqu id levels

• Longitudinal fluid It'wls, indicating that Ihis is a decubuus film lpatil"nllying
on his right videl,

Cause, of massive scrotal t'f\largtm\t'f\t are rare. Filariasis i.. one, but hemiatjon
of bowel is another. It is Ihis sort of f,1'l,l'<S p.lthollOgy that gin'S rb t' to the old
medical jokes about patients having tu ca rry their sc rotums a rou nd in a
wheelba rrow!
00 not forget:
• A Richt er's hernia m,ly til' causing ,1 sev en-obstruction ,1t till' inguinallevel
wi th only a sm,l l! p artial knuckle of b owel Inside it.
• Hennas can occur in ot he r locations, e.g. ,II and a rou nd the umbilicus. and
co ntai n small and /of 1,Irgl' bowel,
• Internal hernias can also occu r - fOf instance into the lesser sac.

70
 Abdominal hernias "'''h'n<!Od

I
Fluid sunk Gas risen
to right to left

Fig. 3.9 -Apo'ient with a huge scrotal hernia. NBThis isa decubitus Film with
tilepatient lying on his rightsideandlarge Fluid levels present with the gos/ying
uppermost.

71
 Consti tion

Look for (Fig. 3.10):

• The characteristic appearance of inspissa ted faecal matter - rounded masses

of mottled or granular texture - due to tiny pockets of gas which they always
contain. Find these and you've found the colon.
• La rger quantities of surrounding gas, with occasional haustral folds crossing
part of the lumen and outward-billowing folds primarily in the periphery of
the abdomen. The transverse colon may, however, be very tortuous and dip
down towards the pelvis as it d ot's here.
• Formed faeces in the right side of the colon. This usually indicates constipation,
as the material here is usually fluid. mobile and amorphous.
• Distension and loading of the rec tum and sigmoid (no t in th is patient). BUI
these too Gill he grossly dis tended in severe constipation. In some individuals
the colon may be distended 10 t ruly enormous proportions e.g.
institutionalized patients who a re relatively asymptomatic but who pelSI'
considerable anxiety when first x-reycd.

Causes of constipation
• Painful conditions - aMI fissure, haemorrhoids
• Social -, irregular work patterns, hospitalization, travel (\ong f1ighls)
• Psychological - institutionalized individuals/defectives, depression
• Elderly - immobility, poor diet, altered routines
• Colonic disease - carcinoma. slow transit, excessively long colon
• Postoperative - childbirth, pelvic floor repair
• Paraplegia - autonomic dysfunction
• Drugs - analgesics, opiates, antidepressants, iron
• Parkinsonism - retardation
• Hypot hyroid disease - generalized reduction in bodily functions
• Chagas' disease - trypanosomiasis infection with megacolon
• Hirschsprung's disease, in children. In this condition look for huge mottled
masses and gas in the surrounding periphery of the colon.

72
 Ccnstipcuc n conlinued

Fig. 3.10 - Constipation This is a 55.year<J1d woman who presen,ed with

increasing obdominal poin. distension, and camp/aiMs of reduced bowel
Irequency Youcan seefoecol overloading in /he Jorge bowel.

73
 The a ix

Appendicitis is the most common acute surgical t'm t'f);t'IlC)o', but most appendices
an' nut visible 011 abdominal X'fay.;.
Often the dtagnose, and treatment are straightforward. but occol.;ion.dly
difficu It or atypical pn'Sl'nt.ltions occur and under the,e ctrcumstaoce, abdominal
films nwy he helpful. First check that ,my woman of reproductive dgt' b not
p~nant. as appe ndioti.. oncn (l('(UI"S in lht' ~'Ol.mg, i.e. ask about the UtP: your
patient molY have dysml'llIlrrhlll·a.
~B A norm al X-n y d oe s not exclude app end iciti s and no one rad iological
s ign confirms it. How ever, wh en certa in radiol ogical signs occu r together in th e
appropriate clini cal setting, the likelihood of appendicitis being th e correct
dia gnosis grea tly Incre ase s.

A word about path ology

Appt'Tldkitis is caused b~' blockage of the mouth uf tfus o~an with inspi~led
faece, or a calcified rna..s lhl'n'ol Ifaeoolithl, k',lding 10 dish'R"ion and infection,
.;umlllnding inflammatory reacnon, bowel sta ..i..and potential rupture - reflected
over lime from t'll>rmality to t'SlJ.bli...bed rad iolog ical changes.
Thi... mg. 3.1) is appt'nJicitis complicall'd ~. d~S tormanon.
Look for:

• Calcined f,1l'r olith.s. ThI'Sl'ffidyucrur ill normal f't"l'I'It'bu t alsooccur in Mou nd

H 'l of p.1til'nts wit h acute appendicitis, and .I.; Ihl' y grow mdY t,l ~t' on .I
laminated apJ'l',u,l I1CI'. Theyare different fmm calri fk d lymph nod ,....A duster
(If four faecnllth s is I'n"it'nl here.
• M,I"S euec t around the appendix. The b!.IWI'lllIOPS are displaced alliolY h-om
the pri mary focus of infection d ue to oedema , ruptu re end abscess formation,
with walling (lff by the gll",ltt'r omentum - 'the abdominal J'l.lict·ffioln' .
• De-tended loop!' (Ii bowel - 'sentinelloops'. The-e are du e 10 localizl'll ileus
from the inflamma tion or matting wit h ad hesions, going lin ttl complete
mtesnnal obstruction. It is the adjacent colon that is distended here.

74
 The a ppendix COtlIiIl.-J

Fig. 3," - Localiied view of erect film of a potiellt with abdominal poin
commencing centrally and then localizing to the right iliac fossa, followed by
increasing toxicity, fever and a palpable moss in the lower rightabdomen and
tenderness PI? on the right,

75
 The appendix COftlinlJe<1

An other appendicilis

This (Fig. 3.12) b the l\lWt'r right quadrant detail from the film ot a 6O-yt'.u -01J
febrile patient with initial central abdominal pain . 1,ltl'r localizing to thl' lower
righ t.
Look .11:

• The curved C -sha ped ut>jo:ct in the right flank

• The black density of its interior.
This is g,lS in the lumen of an inflamed and tUl);id ,'ppt'ndix. It ts it rar e sign and
must be interpret ed w ith cJ ution, .ls it TThly .l lStI occur in normal peopl e.
Other r.1dil,logic.t1 signs tu took for in appendidtis include:

• Free &-1"> - a wry serious stgn of perforati on - either intra ",,'ritoneally or in the
I1'tTllpt'rihllll'lIm (the ,1rpt'ndix canlie in either S!"'lCt'l, but this is ra re.
• u'J>,,, llf the right pso,a.. margin, but again this is ,l non-specific sign.
• Flexion or sl."o1iosis concave to the affected side. This ls natures WJy of relieving
sp.lsm in the muscles on the pa inful stdc. It ma y also be seen in trauma or
n'JIJI colic, but doesnot always occu r.
• Otber indirec t signs of inflammatinnyintra-abdormnal p"thotugy l"ausing h_s
of clarity to thl' right properitnneal fat stript' in thl' [lank, Much is often made
of this sign .
But:
• This art',l shllu ld be included on abdominal films bu t often il is not ,
• You will uftl'n need it tlrighllight to see it, bul often it is too dark 10see ,l nyw.ly
even when the relevant a rea is included.

O ther radiolog ical man ifeslatian s of the append ix

• Remember that the appt'ndh may retain barium Imm a l'\'n'nt enl'md or oral
barium study for m,lny weeks or months. Failure to fill docs not nl'Cl'S.;arily
ind icatl'Jl<.t'a "l'; abo, most patients are nil-by-mouth a" emergencies, tht'reby
pll;'("ludinll oral barium .l~ a test. although wen it to till up with contrast that
would rule out appendicitis ,1S thecause, thu s requ iring alternative p.1 tholo~y
to be so ul';ht.

Point of interes t: Colonic diverticula may retain bari um for man y weeks or
months afil'r a barium enema or meal, cau sing possibl y dozens of \"t'ry den se

76
 The appendix con~"ued

I Fig. 3./2 - Finding of gas in the lumen of the oppendix (arrows).

Opdahl...around thl' (Ilion. If you can !>l'l' what looks like this, jook in the nutl",ur
X-ray pach'l for the rutpnt.
Remember- RI'I,linl.,j barium from r,ldiologicillstudies is a rare but n'O~nill.,j
cau-e nf arpt'ndiritis,
Footnote: Non-mvasive rn'i.lf'l'ratiw imaging ilSSl-"'Sment for 'lpf'l'nJicilis
may nnw N' sought by ultrasound and CT, looking for an appcndicohth, a dis-
tended ,lpf'l'ndi\ >6 mm in di,mll'll'r, and surrounding intlammatnrv signs of
oedema or fluid.

77
 Volvulu s

Volvulus Of 'twbtin);' can atfcct ,11ly pMI of the intra-abdominal g,lslwinteslinal

tract , including the stomach and small bowel, but Ihb is relat ively rare.
Mort>common, but slill Tl'l .ltiwly ran.. compared with allother ca uses of
obstruction of the larg e bowel, is volvulus of the sigmoid colo n ,md the caecu m
in western cou ntri es, although ittendv 10he mort' frequent in Africa, for example.

Sig moi d volvulus

Thi s (Fig. 3.131 usuall y occurs in ddt'rly p.1til'nts who have redundant loops tli
si ~m oi d colon on ,1 long mesentery and ,1 history of constipation. Subacute
rnamfcstations or vague symptoms molY occur bu t in the acu te form the pat ien t
m,l y become !*'wTl'ly ill with abdominal pain , complete consupation an d , on
I'R, an empt y rectum . Dela y in diagnosis ma y lead to ischaemia, gangrene.
perfora tion and death.
Look for:

• Agrosslydislt'ndl'd loop of sigmoid colon cxlt'nding from the pelvis to under

the diaphragm. Compression tll);l'ther of the two medial wall s p roduces the
'coffee bea n sign' , Erect films m,ly show exce....»ve quantities of gas rela tive
to flu id > 2:1.
• A lack I,f haus tra. These a n- df,'cc-d by thl' enormous dislt'nsi on, bu t other
loops of colon underlying it nMy simulate haustra in the distmdt-d loop .
• AJX''t above till' lthh vertebra in the !hIlT,10C spine, aga in a measure of the
S!'\"{'rity of distension that occurs in a true' volvulus. This point is off the top
of this film, which was only one l,f severalneeded to demonstrate the enure
abdomen and chest.
• Convergence Ilf lower margins of the distended loops on the h'ft.
• UWT overlap ~ign - indicanve I,j the J l'gTl.,,(' Clj distension of the bowel. i.c. a
colonic ICll.1p to the height (If Iht' liver OT above it on the right.
• wit flank overlap sij?;Il- indica tive of d istension of the same, i.e. tht'ld t limb
llf the 'coff\"\' bean' owrlil"i the dl'Sl.'l'nd ing colon, which m,ly b- seen behind
it.
• 'Free air' - sign of perforation tnot present here y(1 ).
Thl.... e are tht, d .lssic signs uf a s igmoid volvulus, but in so mt' pat ients tho
radfological signs ,1Tl' atypical and therefore Il"Ss obvious. Rc-tw gr,ld l' running-in
of con trast med ium pl'T rec tu m may show a twisted bea k-like or 'bird of p rey'
sign ,11the poin t of con verge nce III the distended loopsand confirm the d iagO(~is.

78
 Volvulus cont'nlJfPd

Painl af
coeicct
of two
medial
walls

Gra551y Point 01
dilated convergence
sigmoid

fig 3. 13 - SvpineAP radiograph , Sigmoid volvvlus_Anelderly instltutionolized

woman aged 76 with on ccc te exacerbotion of long·stonding intermittent
abdominal symptoms of pain and dis tension, and prior constipation. Note the
distended sigmoid. This is the fomovs 'coffee bean' sign.

79
 VoIVlJIU5 <;()(l~n.-l

This conditi on m,ly respond initially to endoscopic tuba l manipulat ion and
decompre.stoe, but mos t will Tl'CU C. Defmifive su rgt"ry with pa rtial colonic
resection may then be required.
Pe rfor ation and gangre ne co nsti tu te an acute l' ml'rgency and requir e
immediate su rgical mtevention .

Inflammatory bowel disea se

It is not th e rob of plain film rad io log y to es tablish the diagnosis Ilf mild
mllammatory bowel disease, which requires tissue biopsy, but rath er to evaluate
patien ts presenti ng with exacerbations or complications then ot, a nd ot ber than
in obstruction it plays little part in the assessment Ilf smell b owel disease, tor
which barium studies are required. The normal c olon. however, usually contains
semifluid faecal mailer on the rig ht-han d sid e and more sohd faecal ma tter on
the left-hand slde .
In suspected inflammatory large bowel disease therefore look for:
An absen ce of forme d faecal mau e r in the left-h an d s ide o f th e colon.
This ind ica tes that the colon is not carryi ng out its functio n properly, i .e. storing
its contents for a su fficiently long time and absorbing water from them , and these
p.1tients will usually haw a history tlf diarrhoea.
Diarrhoea of course has m.my causes (st'l' nppos itl'l, includ ing gast n rintestinal
tract infl'Ctinns and the use of apenents e.g. in the preparation of p atients for
r,ldiological procedures. At times this can ill' so marked .1S to produce a virtually
faeces-free and 'gaslcs s' abd omen.
The patient's history - e.g. of recent fOll'ign travel , self-medlranon or the
medica l use of supposltoncs etc. - there fore becomes p.lTamllunl.

'0
 Infla mmato ry bow el di sease C()(l~nvN

CaufoeS of diarrhoea
Th~ are conveniently divided into acute a nd chronic.
Acult
• Inft'\1ion~, t'.g. gastroenteritis, food JXliwning
• Dit'lary excesses: lager and hot curries!
• Iravelters diarrhoea due to E.roIi, £"lam,lrM, ShigrlLJ etc.

\'oIt': 'The 'gesless' abdomen, where the X·ray shows a lack of faecal matter and
,dlT1O'>t tlltal absence of gas. may indkate earlv obctruction, diarrhoea or 1.lytiw
use.
Chronic
• Inflammatory bowel disease Kmhn 's, ulce rative colitis)
• ~lJlabso.lrption
• Infection (p.-arasitt"S)
• ~lJlij;n,lnry in bowel
• GI ~ul};t'ry (vagotomy, pa rtial bowel resec tion, blind loops etc.)
• Constipation (in the t'lul'rly) with 'overflow diarr hoea' and rectal plug
• LIX,I!iVl.'S
• Endocrine causes
pancreatic insufficiency
pancrea tic neoplasm
thyn'to"in~is
di'lbt'!ic autonomic neuropathy.

Complications of inflammatory bowel d isease

Small bowel
Thi~ usually involves Crobn's diwa'o(" and plain films may show intestinal
oboolructilln or sij;n~ of fistula fonn.llion leading, for t'\ampJt'.lo air in the urinary
eact (hl.lddt·r, ureter. I"t"lUI pt"hisl or the bili'lry svstern ti.e. bill' duct). Rall'ly
I1Idlign.mcy ma~' supt"' v ene.

81
 Inflammat ory bowel d isease COIIMuod

Lorge bowel
Louk fllr (Fi~. 11·1):

• The ~l'nl'ril lil l'li lack of formed faecal matter

• The oedernatuus folds of mUCIN , l'SJ'l'l'i,llly in the transverse colon .

This is called 'thumbprinting ' and is USUJll y ,1 manifl'Slationof acute a nd st'WIl.'

inflarnmanon in the C<I!(m due ttl ulcerative colilb . Then- are, however, many
(\1U~ of thumbprinting, till' more common ones including:

• Crohn's Jist',lst'
• lschacnuc colitis
• Intramural haematoma
• 1\.1eI,1SI,lSl'5
• Lymphoma
• Pseudomembranous cohns
• Allergic m lCtions ('culonic hi n ,,>'),

82
 Inflammatory bowel disease conlinvod

fig. 3.14 -A43·yeor-okJmon with acu/e diarrhoea passing slime andbleeding

perrecnen. This i5 a 5upine AP film showing on ocuteexacerbation of ukerotive
colitis.

83
 Inflammatory bowel drsecse con'.......d
This (Fig. 1 15) is a case of toxic nwgacolon (lr toxic dil.lIatiollof the colon .
Look f(lr:

• Cencraltzcd or localized dilatation of the lumen of the bowel [» 6(01)

• Lobulated mil~!'ot's in the lumen (inlldmm<1tory P'*'udopolyps)
• Excessive ga~
• Absent faeces (note that the intraluminal masses art' ..mooth and contain no
mottling due to pockets (If gas)
• Gas in the w.ll]llf the bowel (nnl present here. but may indicate imminent
pertorationl
• Evidence of free gas - pneumoperitoneum - 'double wall stgn ' if the bowel
has perforated . Not present here
• Evidence of gas in the portal vein. Not present here. when present this is
usu ally an antemortem event.

Toxic di latation of the colon is an acute surgical eml'rgl'ncy and this patient
required .111 ('ml'rgtmcy rohxtomy, wh ich was carried out forthwith.

84
 Inflammatory bow el dtsecse ,on~n..ed

..

Fig. 3./5 - This is a 35·year.a/d man who wasodmitted in a sfale of shock with
bloody diarrhoea. He hod 0 history of ulcerative colifis_

85
 C a fer 4
Abnormal Gas

• Gas i~ tnt' bud y's own natural contra st med ium and its appt'ardlKt' ,1.. tht'
darkes t dt'nsity appt'.1Tinli on X-rolY films should now be familiM to you,
espt'Ci,llly in the abdomen as wella-, in the chest.
• M(~I t.f the time it is confined to thelumen of the gut , w here ynu ra n ma ke
great U"C of it to deduct' the diameter, and mu cOSJI Sl..l tl' of the bow l'! wall.
HIW.'I'\'t'T, the problem is:
(iI) Ih,1I111l' gut is usually undergoing peristalsis (If varying degrees , solh,11
(h ) enormously va riable qu antities l.f g.tS may Pt.' prt~'nt from p.llit·nt to
p.1lil'nl and from time 10 tim e, both (If which l,u th t' observer ttl lTV
and interpret comxtly. Dilen only ,'arts of tht, bowel an' visible.
(c) adheren t faecal residue may simulate mucosa l abnormality in t1w colon,
as may residual food in the stomac h.
• Much les s fn'quently. but most importan tly from the d iagnosti c viewpoint,
owing to a variety (If "'ltholl ~kal PTIJCt'!O~"S gas m,ly l"S('ape fro m the lumen
of the gu t into the peritoneal cavity, as wellas into the retroperitonea l SP.lO".
• More subtly. it may track into the w,l ll of the howe] ilst'lf and , by fictula
format ion . fu rther break into other sys tl'ms such ,1S the urinary Of biliary
tracts, Of even out ont o the surface of tlw skin tcnrerocutaneo us fislul.l ). Gas
nMy also track down into the abdomen hum the chest, form in abscesse, as
a result of infection with ~ps- rroduri ng organisms, ,1ppt.',U ill vessels such as
the port.r l win ,IS a preterminal even t, and alsoappear ,I S ,1 result of i,ltmgl'nic
activities suc h as em bolizeuon procedures re.g. in the kidn l'y ).
• It mo st be undt'~llll>d that extrelumnul intraperitoneal gas is to No expected
after surgl'ry, laparoscopy or pt'fitonl'o11 dialysis, so that the radiolugist must
be given thl' relevan t clinical inforrn.rtiou and nol Ix> misled intu di,lgnosing
pathtlll~Y incorrectly as ,1result of failure by the chntoan to provi de it.

86
 Abnormal gas con~fliJf!d

• Conversely after ,In iatrogenic procedure such as endoscopy extraluminal g,IS

should not be expected, and its prl'st'l1n~ in tha t situation indicates a
catastrophe, i.e. perfo ratio n of the gut. Th e pro cedu re need not have been
technically d ifficul t for thi s to o.. . cur.

Pneumoperitoneum

The radiological signs of a pneumoperitoneum are among the most important

signsin radiology, indeed in medicine. Somettmes the amoun t of free g,lS is sma ll
and you may have to work to demonstrate it. Miss it and the patient may die .
1 t ook for:

• Bilateral da rk crescents of g,lS under both bcmtdaphragms. NB Figure 4.1

was taken erect, so the gas has risen . This is a large p neumoperitoneum , but
small amounts of gas require time to rise to the subdia phragmatic position
so it is a good idea to leave the patient upright for 10 minu tes toallow this to
happen before taking the X-ray
• Gas may appt'ar on one side of the abdomen only, usually the right
• No gas may be seen if the perforation has been scaled off by the omentum
• If only a small amount of g,lS is present it may be missed unless the film is
centred at the level of the diaphragms - usu,llly a chest is centred around the
fourth thoracic ver tebra. With at tention to de tail as little as 1m! of free gas
may be demons trated.

87
 Pneumoper itoneum COfllinved

Fig. 4. I - B.L Erect CMsl film. 6O-yeor<J/dpalient with0 hislory oF uker disease,
presenling with acule abdominal pain and boarcJ.Iike rigidity in the abdomen.
Note the bilateral radiolucen' collections of gas under each hemidiophragm.
This was due 10a perforated duodenal ulcer. There isalso a moss in the left lung.

88
 Pneumoperi toneum «>nlin..-i

Supint'films will usually have been taken mutint>ly with tbe erectones.and certain
JnOl\'subtlesignsof free-gas in the peritoneal cavity have been described to enable
thediagnosis to be established under these orrumstaeces.
LOllk for.

• 11Ie double-wall' sign (Fig. 4.2), i.e. bot h stdes of the wall of loops (If bowel
become visible because of air on t il l' inside and air on the ou tside - try to
find an isola ted viscus surh as IhL' stomach Of bow el loop, but remember
that c1O!'ol'ly apposed loo ps m,ly give J false positive 'double-wall' sign
• ' Football or d ome sign'. With a l,u ge pneu moperitoneu m the und ers urface of
lht'di.lphragm may be-surround ed by air,giving a darkdome-like apP'-'drdnct'
in the uPJX'fabdomen even on supine films
• visualization of falciform ligament - 'Si!Vl;'T'S sign'
t Cas in Ilk' scrotum in children
• Inseriouslyill patients theu~ of erect films may not be possibleand decubitus
films with the left side down centred on the right u ppt>r flank should be
taken.

Bri!\ht lights m<1 Ybe rcqc tred to St't ' this art'a propt'rly, as for technical reasons
thl' films often come out very dark in this situa tion .

89
Pneumoperitoneum con ~nued

Gas at falciform ligament

80_
sides
seen
he..

- Only
000
side
01
colon
wa ll
~"
here

4.2 _ Pneumoperitonevm- 'double-woll' s;gn. This isa wpine abdomenshowing

some of the more subtle signs ofa pneumoperitoneum.

90
 Pneumoperitoneum COIl~JW<fd

Thl' CJ IlSt'S of a pneurnoperiton eurn art' legion and are oft.. . n divided into those
with clmealstgns (If peritonitis <HId those wit hout, although some of the latter
may later develop signs (If peritonitis.
Cruci. l f. ct: Special vig ilan ce mu :o>t be exe rcised in dealing wit h patients on
luger doses of steroi ds. These dru gs both pr edispose th e pat lentto ero sion and
perforation of the uppe r GI tract and then mask the sy mptoms and signs. Th e
diagnosis of perforation then relies entirely on the X. ray, so iI h igh ind ex o f
suspicion for th is phe nomenon mu st be main tain ed.
Nott' (Fig. 4.2):

• The diaphragms an- not visible, nur ,my gas beneath them
• Free gas , however, is dclini lt'l}' present as both the inside and outside wa lls
of parts of lilt' colon art' visible , i.e. the ' dou ble-w all' sign
• CoilS is tracking up the fakiformligament.

Causes of a pneumoperitoneum
With pni toni tis
• Perforated peptic ulcer (stomach or duodenum !
• Intes tinal obstructi on
• Ruptu red d iverticula r disease
• r l·llt.'trating in jury - gu nshots, knife-wounds etc.
• Ruptured inflammatory bowel di~'aS(' te.g. mt'gat'o lon)
• Colome mfections (typ hoid ).
Withou t peritonitis
• rvst ldpamtomy
• r(~ldpa~lpy
• Jejunal divertirulosi..
• Steroids
• Trdcking from cht...t Ipneumothorcx)
• Pentoneal dia l ~is
• Vagina l insufflation (d ouching, squatting, oral sex , postpart um exercises .
water-skiing)
• Pneumatosis coli.

91
 Differential diagnosis of a pneumoperitoneum
M,my im portant phenomen a can sim ulate a pneumo periton eum and lead 10
mi..Jiagnosis a nd unnl'\.~ ...H )' surgt.'Ty, wit h all its medica l and medico-legal
com plications. A good selection of these is shown to emphasize their crucial
importance.

Linear cteleocso (Fig 4 .3)

• Linear att.'lrt1.lsis is a phenomenon that occurs in the lungs, usu.llly at the

00_ .
• It is frequ entlv olSSll(i.lll'd with infectum or pulmonar y emb olism and is
com monly seen afll'r anaesthet ics in the posh'f'l'r,ltive st,lt,'. II form s ..1"11""
horizontalor curved bands which m.1Ysimulate the diaphra gm.
• Noll;' how the band atthe righ t costoph rentc anglt' curv es up mstead of down.
Norrreny it resolves within days or Wl"t.'k..., hu t may persist for [llngl'r.
:-.iolt.' (Fig_ 4.4, r-':I4l:
• 11k'band of iocn-ased dt.'nsity running just dhow the med ial p.trt of the ri~hl
hen udiapbragm, CTt'ating a Iccent view lIf the air in the lung beneath it and
simulating a pneumoperitoneum.
• This is a more subll.. e ...ample of linear atelectasis following anaesthesia.
Nolhi ng had ht...·n done 10 the abd omen.

92
 Differential diagnosis of a pneumoperitoneum rorolillued

Fig . 4.3 - This is a case ofbiloleral/;near ole/eclas;s simulating 0

pneumoperilaneum.

93
 Differentiol d iognosis of 0 pne umoperitoneum continved

Bond of linear atelectasis

Fig. 4 4 - This is a postopero,ive generol anaesthetic pa,ienl who has iust had
ENTsurgery Detail from figh, boseof a chest X-ray_

Chilo iditi's syndrome - colo nic interposition

Note (Fig. 4.5):

• The inciden tal find ing of pockets of gas beneath the right hemidiaphragm
• Multiple bands {If mucosal folds indicating gu t. This is colonic interposition.
An abdominal film ShOWNcontinuity with the rest ot the colon
• Rarely the sma ll bowel may interpose as well
• This Oldy lx· intermittent in nature, i.e. presen t on one occasion and gOHl' the
next.

It may Pt.' seen with shrunken livers (cirrhosis), in COPO with a large thoracic

9'
 Differential diognosis of 0 pneumoperitoneum conrin..-d

fig. 4.5 -Chiloidiri'J syndrome Colonic interposition. This is the chestX-roy of a

60-year-old male with chronic lung disease.

outlet, ro~llll'l'r<ll i\"dy when the ~urloil"n has pu ..hed the gut out of tl1l'W<l Yl0 j.;l·t
at 'lllffil·thinj.; d "'l', Of ~pl >n l<l n'·l.lu ..I,!.

95
 Differential d iagno sis o f a pne umoperitoneum ronli"ued

Meteorism

Look for lFig. 4.6):

• ExC\"Ssi\'E' air swallo v..ing ott en associated with crying. espeoauy in children,
ca usi ng gut distended with gas to cro w d up underneath both hemi-
diaphragms. tlnterposmonagam lID the nght.I
• Folds of the bo w el crossing the ga.... filled lumen, confirming the pn.'Sl'Jln' of
gut
• Superimposition of bowelloops
• Co ntinuity (If loops wi th oth ers in the abdomen.

This is meteorism. Thl'rl' were no abd ominal symptoms and nu perfora tion .

Subp hre nic cbsce ss (see Fig. -4 .15 )

• Fluid levels under eithe r benudaphragrn. more commonly the right.

This usuallv occu rs postoperatively in a wry !>id.. pdtil'flt. Part (If the gds .....ill
ntten han> been gl'nl'ratt'd by organi-om!> and will nut all hi> residua l from the
lapdmtnmy. Ultrasound may be wry help ful in dl'mll nstrati nf; fluid, but w iIl
tend to hi> bloc ked by .my f;as that is present. CT may then be required . PL.J in X-
r,lys, ho w ever, etten frrst alert on e to the d i ,l~n lls is .

96
 Differential diognosis of ° pneumoperitoneum I;",,'inue<l

Fig, 4,6 - Childwilh meoleorism This isrile X-rayofa yovng child w ith a suspected
chesl infection who hadbeencrying profusely beFore the Film was token.

97
 Rarer problems cau sing a simula ted pneumoperitoneum

• Skin fnlds, especially in the elderly, infants and severely dehydrated patients
• Cortical rib margins overlapping diaphragms
• Lobulated diaphragm with gut underneath one or more humps.
This is a matter for careful inspection and analysis of the films.
NB When there is doubt about a preumopcrttoncum or demonstrating the
site of a leak is required. ora l water-soluble contrast (but not barium) can be
given to try and demonstrate a perforation, unde r screening control by a
radiologist. Barium should not be used as it is harmful and dangerous should it
escape through a perforation into the peritoneal cavity, exact-rooting infection
and causing barium granulomata.
NB Just occasionally one Of other of these phenomena can coexist with a
genuine pneumoperitoneu m. Dual patho logy is by no means unheard of.

Fal beneath the diaphragm

Look fur (Fig.4.7):

• Constant radiolucent stripe beneath the left hemidiaphragm

• Constancy in the size, shape and position over time and no movement with
change of position, e.g. a decubitus film
• Associated cardiophremc fat pad at the apt-'x of the heart.

This is a hpoperitoneum, i.e. a collection of fat beneath the left hemidiaphragm.

Note its similarity to a genuine pneumoperitoneum. A hpoperitoneum is more
likely to Of cur in an (I~ patient or one with a cardiophrenic fat pad indicating
tendency to form excess body fat. The lucent lint' however is not quite so dark as
gas giving an important due to the diagnosis.

98
 Rarer problems conhn.-/

lucent stripe allot simulating 0 pneumoperitoneum

Fig. 4] - Deloil From one of a number of idenhcal chesl X-fOYS taken on !his
patienl over several yeors.

Distended golslric fund us

This can form a n e ... ten stv e quant ity o f a ir a p pa re nt ly beneath th e left
hrmiJia phragm.
Look for.
• A fluid level in the l'rt'ct position. as st.'l'n on most norma l chest x -rays
• Typical disposition of the stomach in continuity with gastric funduson supine
film
• The totalthickness of theleft hemidiaphragm. A 'na ked' dia phragm with fret'
au-on either stde of it measu res only 2- 3 mm . With the thickness of the gastric
fundal wall beneath it the total thick ness will approximate to mort' like 4-
5 mm in total. Proceed with caut ion, how eve r. as excepn ons can (llUJr.

99
 Ga s in the retroperitoneum

On occasion gdS molY collect in the ret rope ritoneal sp.lce and cause a so-called
p neumoretrope rnoneum . However, il is u~ually d ue to rupture of parts of the gut
with retroper itoneal cornponentv, e.g . the d uoden um o r rect um. either
sfll.lntJ.Ill.'l.lusly due 10pathology or following instrumentation. such as t'Tldosropy.
or pt.'tll'traling injury te.g. a stab wound).
At ,lnl' nme the deliberate introduction of gJ.s inlo the retroperitoneum Wo1'>
earned out a..a diagnostic procedure. by in>ot.·rtinl; a needle Ihrough the perineum
and injl'cting carbon dioxide - 'presacral pneumography" - 10 demonst rate renal
or adrenal masses, hut this is now completely obsolete. Neverthel.....s Ihis
iI1u..tranon of the technique ..how.. well what to expect and what you will see
when it occurs.
Not(';
• The intt'n'ot' black o.1t'nsity sumlUno.1 ing the rstMS muscle margins, the kidnt'Y'"
adl\'nJb and spleen
• M,lr" t'l.1 t·nldTgt'mt'n t nf the right adrenal and spleen
• Ass("lci,lIt'd gas in the pe riton eal cavily, which nldY or mdY not (,IS ht'rl') bt'
pre- ent.
NH C,l" in the rctroperitoncum is a >ot.'rinus r,}J iological sig n ,100.1 n-qu in'!l
urg" nt ,l....>ot....cment to find it.. CdU~', ,llthough the preceding his tory i.. u!'>u,}lIy
obv ious.
:\8 A lack of gas u nder e ither he mid iaph ragm on erect films does not exclud e
a perforatio n, ,10 0.1 air in the retro peritoneu m will nol necessari ly be .a...socia ted
wit h .Iir u nde r e ithe r hemidiaphr .agm . A pecte riorly perforating ulcer m.ay lead
to .air only in the re troperito neum. l n I1I11 SSi i ' t pe rforations free gas m.lYreadilj-
be wen under bo th he midiaphr .llgm .... even o n SUI, int films.
Ofil'n, however, retroperitoneal gas is pre-ent only in small quantities .mJ
('\Ii'l.. tilutt~ d subtle radiological finding.

But do not mistake streaks (If dirt in tilt' erector spillal muscles fllr I\'!rnpt-"Ii-
tol1t.'al gdS in the t'lderly.

100
 Gas in the retroperitoneum c~

Right Very dar];

odrenol retrcpe rhonec l Spleen
go, I

Fig. 4,8 - Retroperitoneal gos - old X-roy From a deliberofe case of 'presacral
pnuemogrophy'. Notethe intense 'negative contrast' highlighting 01thekidneys.
Nate also the enlarged spJeen and big right adrenalgland.

10 1
 Postoperative abdominal X-r s

There ,11\' so me important facts worth emrha~izingabout these films . FTt'!' gas in
the abdomen is oOTITlilI after sU'l;ery and usually diminishes d ol r b)' dol)" on the
early supine films. If the amount of gas does not diminish it may indicate the
breakdown of an anastomosis or It'aJ..agl· from the site of recent surgery.
After several days , when the patit>nt is feeling better and sat up, the gas n-es.
and it may then appt'ar that a lot mort" of it is suddenl y present underneath the
diaphragms when previous supine or semlrecumbent films art" compared with
erect ones. Remember this phenomenon and monitor it Mort" misdiagnosing a
1t'alo: . The patient's clinical state will be d go..ld guide.
Tips:
• Take advantage of any view of the lung bases you get on abdominal films.
The amou nt of energy required to demonstrate the abd omen is much greater
than for a chest X-ray, and lung bases that 'ca nnot be shown ' due to obes ity
or poor inspi ration on co nven tional Chl~1 x -rays may show u p pa rticula rly
well on abdominal films - for basal atl'lt'Cl.lSis, effusion s, cavities, meta stases
etc.
• Askin g for 'an upper abdominal film" m.1Y be a sub tle WilY of gettin g the
r,ld iogrilpht'r to show the lung bases for you.
• On pos toperative films look particu larl y d ost'ly for signs of left lower lobe
and linear colla pse. Colo nic uue rposition mily also occu r postoperatively
• Do not forget to loo k ext remely cri tica lly at the position of all tu bes. d rains,
stents and coils that may haw been p ut into the abdomen and maintain a
high ind t'll of suspicion for sigQS of inft'd ion, ileus, etc.
• Remembe r ea rly post-ope ra tive films may ha ve 10 be do ne on mo bile
machines and be technically 1t>S.... Sdtisfactory and mort" pront' to artefacts .

102
 Gas in the bilior tree

This has alread y been touche d on un der ga lls tonl' ileus. Re me mber, t he
gallbladder and bill' duct are not routinely li,ible on pla in X-rays and, when
illustrated in texts. haw usually been injected wit h contrast mediu m so that Ihey
show up while . It is im portant, however, to leam to idt'ntify familiar anatomical
structures prese nting in a n unfam iliar W,l y, that is, wh en outlined by gas. Th is is
known as ' negative contras t' .
The clinica l stall' of the patient will be a g(lod guid e as to the potential
seriousness of finding gas on X·ray in the biliilry tree, e.g. very sick with gas-
forming org anism in fect ion , or clinicall y well d ue to p rev ious choledoc ho-
duodenostomy surgl'ry.
In the p<!st carbonated d rinks haw been given to child ren with bill' ducts
anastomosed to the gu t to fill them with COl a nd monitor their subsequent size
- a form of 'coca-colagram'; thereby avoidi ng the risks of iodin ated contrast.
UllJd".mnd would now be used, howev er, and can de tect gils by brigh t echoes
coming from the bile d ucts.

Gas in the wa ll af the gallbladder

Asopposed to !}IS in its lumen, g,15 can occu r in the wa ll of the gallbladder itself-
so-called 'emphysematou s cholecystitis'> d ue to infection wi th gas-forming
organbms, especially in d iabetics. It look... similar to gas in the wa ll of the uri nary
bladder (Sl'l' Fig. 4.12). Other Ih,111 those slated on page 63, causes tlf gas in the
biliary tree includ t>:

• Crohn's dtseese
• Pancreantis
• r.uasi tt'S, l'.g. ascmasts .

103
 Gas in the urinar tract

As with gas in the biliary tract, the findi ng of gas in the urinary tract usually
indica tes recent instrumentation or else something serious ~oin~ on, such as ~as­
forming infection or fistul a forma tion.
Causes of gas in blad d er lumen (see X-ray nn p. 182)

• latmgemc, e.g.cystoscopy
• Out' to fistula form.mon.

Causes of bladd er fistu la

• Malignancy of bowel, bladder, genital system
• Cro hn's disease
• Diverticular disease
• Po stoperativ ely (controlled trauma'}
• Trauma (uncontrolled}
• Radiotherap y
• Foreign body
• Ulcerativecolitis.

Note (Fig_ 4.9);

• The distension of both collecting systems from the obstructing effect of the
bladder carcinoma
• The white outline of the left renal collecting system by contrast medium - the
usual 'pos itive con trast' from the i.v injection
• The blac k ou tline of the right renal collecting system, i.e. ' negative contrast'
from intrapelvic and intracakycal gas on this side, plus the non -fu nction of
the righ t kidn ey.

104
 Ga s in the urinary trcct COIl,ill.-l

Fig. 4:9 - Gas in thecollecting system. This is the Film of on IVU sequence From
a pahenl with 0 corcinomo of the blodder who, in addition to hoematurio,
complained of possing 'Foam', with bubbles in his urine. A Fistula hod formed
with the bowel, ollowing gos/o enler the bladder ond the rightureter,

105
 Intramural gas

H,wing assimilated the norton of gas as the body's natu ral contrast agl'nl for the
purposes of diagnusis within the bowel. and evidence of the wry serious situation
of t"SCape and leakage from it. it is now nl'«'S..y.ry to recognize and understand
the significance of gas in the W illi of certain stru ctu res, where it may {l('('asionaUy
be found Isee below) , e-g- the bladder,
Intramural gas may appt'ar virtually anywhere of course, but in practice a
c ommonly important place to look for it is the colon, I'.g. in chil dren.

N ecrotizing enteroc o litis

Look for (Fig. 4.10):

• Intramu ral colonic gas, especially on the right-hand side - note the d,uk
margins forming a connnuous track
• A normal appearing loop of bowel in the left flank with a normal wall of soft-
tissue d ensity contras ting with gas in the lorren
• Cardiac leads. Moniilm ng of the child n>t1t'C1s the severity of its condition.
The child has also been intubated tnote the endotracheal tube).

There are many causes of intramural gas, a list of which is given after several
mon' examples (page 11 0).

106
 Intramural go ~ conlin.-J

lnlromurol_
9"

Fig, 4.10 - A young infant presenting wi,h prostration and bloodydiarrhoea.

Note the veryclearedge ofthecoJon outlmed bygos in the wollof thebowel.
This iJ necrotizing enterocolitiJ.

107
 Intramu ral g as con'i"UfId

Pneumatosis coli
Look for (Fig , -1.111:

• Ga"C)'.,ts pmtruJing inlo the lumen of the 1aJ};t' bowel causing a mulliplidty
IIfsmall pockets, far in t'1la'SS of normal in the right uPJ't'l' quad rant
• Di..tornon of tnt' normal mucosal pattern
• Evidence o f perfora tion (not present here! - this may be locallzed or
gt'neralized, i.e. a pneu moperi toneum. or track i n~ into the mesentery. The-e
'pop pmgs' of the /;<1S cysts a n- us ually benign but present wi th rec u rrent
bouts of abdomina l pain.

Tht'rl' nl.1Y be an dss.xi,ltl'U colitis in these patien ts an d l>ccasiunally a p-ychiatric

hist(lry.
Mulhpfe gas cysts

Fig, 4. " - A54.year-<J/d woman with fecurren/abdominal poinond diarrhoea,

This ispneumafosis coli.

108
 Intramural gas COI1hnued

Gas in the bladd er wall

~(ltr (Fig_ -tI2l;

• The multiple irrt>gulaT lucent pod,t't~ overlvmg the arc of tilt' bladder outline
• This is '("ffiphy!>t'md tou ~ cystitis', d"~OCi.ltloJ with gas-forming urgani..ms in
11K- wall of the bldddl'f
• A large rectal plug ..urrounded by gds ca n look similar, so caretul dnalysis is
f\l'('('Ssary but the got.. mdrgin i.. usuallv srnt)l.lth.

I
Fig, 4.12 - This is thelower abdominal X-f0Y of a 50-year-old man w ith severe
IIrinory trod infection. The pohent was diabehc.

109
 Causes of inr,.cmurcl gas

Common
• Inf lammatory bowel duea..... -mily be a ~i~nof impend ing f'l'rfuralion in toxic
dilJ.tJ.tion of the colon, J.complication of ulcerative colite,
• lschaermaof the bowel causing incipient nt."OllSis/infJ.rction, JUl' to.
strangulation
volvulus
necrotizing ffitt'rncolitis
obstruction [premature infants)
• l'neumatusis CYSlllidl"S. Usually benign. Onen ,In inddl"Ilt,l l finding on X-ray
(p. l Oll).

Rare
• Diabetes with infected gut wall (J.ISll g,lllblilddl'r and urina ry bl.lddl'r)
• Iatrog enic (post l'flJOI'CUpy, biopsy surgery)
• Obstrucnve pulmonary disease tradun~ down from chest (.l~lhl1ldtics, CDI'D
patit'nt5)
• Pt'plic ulcer diSl"dSt'
• Peneeranng injury
• Steeolds tmav be stlenn.

110
 Intra-abdominal infection

Approach to the problem

A vt ry high indt t of susp irio n must always lit' maintained for the ~~ibility of
intra-abdominal infection, especially in pt ..... toperanve patients who do nut recover
quickly aner surgl'TY.
This is also true for patienls who all.' ju!>t vaguely unwell but pyrt',ial on
admission, as well .IS tho!>t.· with localizing signs.
Common major ronce ms are the subphrenic abscess after su rgl'fY, and
pericolic abscess formation from rupture (If the ap pendix or an infected colonic
divertirulurn, although these will usually N' accompa nied by pain. Penetrating
injrries are also a potent SOUTCl' of transfer of ba cteria into the a bdomen (knives,
bullets etr.I, causing peritonitis.
Abscess formation lead s to pus, and a l.ugl' liquid collection m,ly be readtly
detected by ultrasound (If CT but remain only as a vague mass dl'nsity Of even
undiagnosableon plain films. In the presenceot gas-forming organisms, however,
tither multiple small bubbles Ofabnormal larger collectionsof gas and fluid may
mabk a plain film diagnosis of abscess formation to lit' suspected , and indeed
thegas thus formed may block acoustic access and render the plain film superior
to ultrasound for diagnosis in this regard, but no! CT.
wteo en abscess is forming in a ca\ity the semisolid materia! milled with gas
bubbll'S may give it a granula r texture like faeces, so caution must be exercised
heft'.Agood clue to the prt'Sl'flce of an abscess is the constancy of its posjtl on , so
'look for the gas that has not moved' on serial films. Try to gl't vrcct Ofdecubitus
films with the affected side uppermost, in addition to supine films. Normal gut
undergoing peristalsis cau ses changes in configu ration minute by minute,
although ileus may complicate the situation. Sentinel loops may <lp pl'ar around
anabscessbut will tend to lack mucosal folds. It is easy to mistake a fluid 1l'\'I'1in
an abscessfor just another loop of bowel in the early stages of its evolution.

111

!
 lnno-cbdominol infec tion continued

Fig. 4, /3 - This is thesupineAPfilm 01 a 72-yeor. old man admittedwith marked

left /ower abdominal poin and renderneu. The patient was known to have
e}(tensive diverticular diseo!e, most profuse in the sigmoid. This is on anterior
abdominal wall abscess caused bytrocking oot to the left from on infectedruplured
sigmoid diverticulum, which hoderodedinto the lower left overhonying {obesityJ
anteriorabdominal wall.

Look f~lr (Fig. 4.131:

• The large left-sided circular lucent ,11\'a over the left hip, left iliac blade and
left pelvic region . This is ga~ lying anteriorl y in it largl' abscess cavity
• The muttipledenseopeotie, in thcpelvts - this is rel:'lint'll barium in diverticula
from ,1 p revious enema. indicating that the piltient has diverticula r disease,
and indicating alikely cause for the current problem
• The large gas-liquid level over the left hip region on the second erect film
(Fig. 4.14l. The weight of the fluid ,10.-1 g~'lll' ra l downward movemen t of
stru ctu res in this position is typica l. II is too big. high a nd lateralto be euher
it femora l or an ingui nal hernia . N~'l'llle aspiration con firmed pu~.

112
 lmro-cbdominol infection COIIhnueC

I
Gos-liquid level

fig, 4 14- Lefllower anterior wall abscess (erect Filml ,

113
 Intra-abdo minal infec tion Conhrl.-i

N B Occas iunally an abscess may form within a sulid organ, (w ating a ga.. -
liquid level, e.g. in till' liver; spleen. and of ("(JUN' the brain .
look at (Fig. ·t IS):

• The g,IScollectiun under the right herrudiaphragm

• T he assodated fluidlevel...This is pus in the abscess, indicating mult iple locu li
and an erect film
• The thi nn es.. of the right bemid iaph ragm, indicat ing t his b a 'na ked
diarhr'lgm'
• The absence of .my mucosal folds , supporting tht' conclusion that this is not
part of the gu t, i.e. colonic interposition, or interposed sma ll bow el,
• Elevation of th e right hermdiaphragm . This m,ly or m<1 Y nul be pr esent .
'Splinting' of the right hernldiaphragm m,ly alsu occur, i.e. pa ralysis on
screenin g, but 'screening of d iaph r<1gm s' is now an ant iquat ed concept and
does not rule ou t a subphrenic abscess.
• Evidence of an ,ISMIC'i,llt'J pleural effusion Of lobar collapse on rl u-same sillt',
which m,ly or mol Y ntlt be prl'S('nt (not ht'rd .

Cu nfirmat ion and imagi ng gu idance fur drain age may be ea rned out under
ultrasound or cr control.

"'
 lntrc-cbdcmincl infection conhn.-l

Fig. 4 15 - t~h, wbphreftic obscl!'u A 63· yeor-old woman who hod a

choIecysledomy corried 011' 8 days before. who is now pyrexial ond tender in
the righ, upper quodrant. This is a large righ~ sided subphrenic abscess.

115
 C a tar 5
Ascites

The accumulation of free intra peritoneal fluid in the abdomen is an important

clinical finding confirmed by the class!c clinical sign of 'shifling dullness',
Rad tologtcally a sign of massive free fluid includes distension of the abd omen.
In the supi ne position the bow el will tend to float on lOp of th is poo l of ascitic
fluid and lake up a central position. Some separa tion of the loo ps themselves
m,ly also ocrur b..X:ilUSI' of the accumulati on of fluid between them.
Ab u look for:

• A bulging shape to the abdomen

• A dense central grl'y part and sharp cui-off Idll'rally, with dark flan ks, due 10
the mar ked distension and abrupt change in curvature-of the abdomen
• Greyness or 'g round-glass' apf'l'<uance JUl' to red uced con tras t, and increased
Wl'ynl'Ss caused by Increased scattered radiation from Ihe distension and
fluid
• Med ial d isplace ment (,f the colon ,1way from properi toneal fat stripes, of the
inne r abd omin al wall. To he seen, this usually requires a brigh t light behind
the film
• Loss of definition of liver lip, psoas margins, kidlll'}'s etc.• due 10surrounding
fluid . As little <1S 7-10 ml of fluid m,ly cause the liver tip In disappear
• Elevation of both hemidiaphragms (severe C,lSl.~) ,

Causes of ascites
• Hypopr oteinaemia (loss from gu t or kid ney)
• Cirrhosis of liver
• Congestive hea rt failure
• Inflammation (panc reatitis, tuberculous nodes]
• Malignancy with per itoneal metastases
• Lymphoma
• Occlusion of inferior vena cava

116
 Asc ites con~n.-J

Fig , $ .1 - Asciles Supine radiograph of a cirrhOh'C 48-year-old po,ienr with

centrally ploced loops of small boweland a distended abdomen. Thi, is ascites.

• M,lInulrition
• Nt'phwlic syndrome
• Constncnw pericarditis.
A'<itt'!"o usually "!<lrt'> toaccurnulate in the pelvis.tracks up the paracolicguucrs.
tlwn gr<ldu,llly fills the abdomen.

117
 Cater 6
Abnormal
intra-abdominal
calcification
The causes of pathological calcification within the abdomen art' man y. Onl y the
mort' common an d importan t ones encountered in everyday clinical radtojoglcat
practice will be described.

Abnorma l vascular cclcilicc tion

First remember that impo rtan t medical conditions such as diabetes and chronic
Tl'I1<l1 failu re can cause premature vascular ralciflra tlon - another good reason
for checking the age of you r patient bo th on the name badge from the date of
birth and against any established degenerative changes in the spine.

Aorta/aortic aneurysms
If nCH's.<;ary. go back and revise the section on the normal aorta {PI' 24--25}. Gel
into the habi t of IOllking for the aort a on l"'lwy abdominal film, young Of old . If
neu'Ssary make it your 'favourite organ' (set' hints at end of book).
Crucial fact: You mu st develop a very high ind ex of sus p icio n for abdo mina l
aortic an eury sm b ecause th is con d ition is so dangerous yel so poten tially and
emi nently tre atable by su rgery or stenling., and it is frequently pick ed up as an
in cidental find in g on p lain abdom ina l X-rays.
The pa tien t's life is then well and truly in the hands of those who see his
films, and abdominalaortic ,1Ot'urysms haw repeatedly been missed on X·ray s
in the past , these patients subsequently dying suddenly when they ruptured.
If you learn not hin g else from th is book, learn to be ruthless in seek ing uut
aortic aneu ysms!! Ten second s' search iog may save the pati ent's life.

118
 Aor tic an eurysms continued

Fig. 6. 1 - Aortic aneurysm A 65·year-old diabe ric and lirelong smoker. Note
me large calcified moss bulging totile left. This is onabdominal aortic aneurysm.

look for (Fig. 6.1):

• The typicalthin line of calcification in the wall of the aorta. Most .1I1l'urysms
bulge 10the It'fl, bu t occasionally thl'y may bulge to the right or symmetrically
about the midline and stillhe entirely over the spine
• Associated calcification in tIll' iliac arteries, which is <Ibn present here.
Aneu rysms may form in these ves-els as \\'1'11.

119
 Aortic oneurysms r;t;HIlinued

C linical/ra d iolog ical problems

• TIll' physiciannr su rgeon may think he feclsan aortic anet l!)'5rn in thea bdomen
a nd requests a n X-ra y ' to e xclud e it ' , Thi n pa tients, o r pati ents wi th
except ionally lordotic spin es, mol Y we ll haw a very palpable or 'thrus ting'
aor ta , ,lS may hy pertensives. so A nor ma l aerta m Ay s im ulate An
Aneur ysm .
• An obese patient may have a big ant'u rysm which cannot be confidently
palpated. although you may lit' able to fee l it when you know it is there!

NB In abilit y 10 palp ate an a nt'ury sm does no t mean th e pat ient has not got
one. You should not be d igging 100 hard a nyway, in case yo u bursl .In
undia gnosed aneurysm.

• Mos t aneurysms contain thin rims of calcification in their walls, but overlying
gas. colonic man-rtal and X-ray scatter m,ly make them nory hard to find .
The edge of the rim may lie just at the edge of tht' spine and be misinterpreted
as part of the spin e.
• Someaortic aneurysms have insufficient caktttcatton in their walls to lw seen.
but norma l anatom y may save the day.

Look fur:

• A normally calcified aort,l (p,ltit'nts ove r 40) ove r the sp intowith pa rallel or
converging Willis; this d(lf5 exclude an anvurysm. but both walls mu st lit'
unequivocally identifi l.,j to doso.
Be aware. how....vet, that not t"l'l'TY body's aorta calcifies - 1'\' t' O in theelderly.
Poin ts 10 po nder: I. Around oOIXl men die in tlw UK each p 'ar from ruptured
abdominal ,lOI'UI)'sms, and some I.f them have aln',l dy had abd ominal X-rays
taken .
2. Albert Einstein died of <'I ruptured abdominal aortic anl'Urysm ,

120
 Aorlic aneurysms conlin..-l

Oher more complex problems

• The aorta lTIdy be tortuous or bent but not aneurysmal. an aTll'Ury!>m in an
arM,. beoing defmed a!> loss of parallelism in its w alls .
• OnlYOlK'of the two w allsof a tortuous but parallel-walled aorta Illdy be visible
- usually on the Idt. 1IIl.lking like an anWl)'!>m w hen one is not rn~'fll.
• A true aneurysm may haw one w all bulging to the right of the spine - get
used to looking for it hen' as well.
• Rarely some am'Ury!>m~ are so large kg. > 8 em) and their calcified walls so
far apart and atvpfralthat they go undetected if the observer is unaware of
this phenomenon, ur they may blend with the sac roiliac ~li nls tow er down.
• Musl ant.'Urysms an' asym ptomatic.
• Vt'!')' rarely the-superior rnesen tenc artery may caki fy and, taking a long curved
CUUN 10 the Id l of the -pine. may simulate an aortic ant'UTysm . In this
situation . ho w ever, the aorta itself is likely 10be ralo fied and should be visible
asweD.

look at (Fig. 6.2):

• The thin rim (If calofxanon 10 the left of Ll and distal to it

• The even more subtle rim of calcification to the right of 1..4 adjacent to the
lumbar spine.

The patient had non ·op,lque ga llstones . This was the typical incide ntal
radiological presentation of an abdominal aortic an t'urysm. or 'triple A'. It was
missed by the first two doctors who k-..l"l>d ,1t lht' film.
Look at (Fig. 6.]) :

• The unequivocal fO(,11 expansion of the calcified wall of the abdominal aorta,
confirming the prl'Sl.'flCl' of an ant'urysm.

~B All ilTldg~ on X.ra ys are slightl y magnifit'l..! and thi.. tndude, olnl'Ul)'slmo,
but aortas O\'!"T 3 em are usually ~nJt'\l .I .. allt.'Ury~lTIdl . SOITlt;' aortas can be
» em in diameter [so-called 't'Ct.1tic'l, but Nt" Jnt'U.ry"1TId1. "0 Illtlk for departures
from parallelism, i.e. l(lUl at the ..hare III the aorta.

121
 Aortic o neu ry~m~ contonued

Fig. 6,2 - This is the supine APradiograph o( a patienl X-rayed (or righl·sided
abdominal pain. The firs t /WO doctors missed Ihe aneurysm.

122
 Aortic aneurysms conhntlfKi

Fig_ 6.3 - This is a lateral view of the some patient. The third cJoclor who sow
/he previous Film was suspicious and requested this further view, confirming me
diagnosis.

123
 Aortic a neury sms cOII/iroved

What To 0 0 7
A~ in m ,tn y other situations the answer to the radlologfcal problem lies in
requesting further views. Do nul struggle on with just one film if you .H~ not
sure what is glling on, but it is best practice to seek help before r..... irradiating the
patient u nnecessarily. Ho wever, if you are alone and still unsure you may:

1. Req uest a lateral view of the abdomen. This will get the aorta off the spine
and you will have a clearer mental pic ture of what you are looking ,H.
2. Req uest a su pine left posterior oblique view (" right anterior oblique view).
Th is is often superior to the lateral an d givt'S an excellent dew of the aorta in
isola tion from the spine, although yuu may find it harder to in ter pret.
Radiologists, however; find this view extremely valuable. The solu tion to the
possible pres ence of an ,lIleurysm may therefore be solvable with plain X-
rays, but ultr asou nd or abdominal CT are Ihe next investigations of choice.

Is it leaking?
An early decision must be ma~e with an acute abdomen as to whether to proceed
stra ight to theatre or whether theft' is time to Image the ao rta, even with plain
films,

Are the rena l arteries involv ed ?

[f the i1nt'urysm extends as high as L2 this is likely, but accessory renal arteries
may be present at a lower level and can never be excluded by plain films. CT
,lIlgiography, magnetic resonance angiogr aphy or con venhonal angiography may
be l1l'Cl~sa ry to confirm or exclude these.
Look at (Fig. 6A):

• The irregular convex edges of calcification 10 the right of the lumbar spine
• The clea r righ t p~(las margin
• Loss of the left rSO,l~ ma rgin and increas ed soft-tissue density on the left
side with a convex edge further out 10 the left.

Th is is a leak ing abdominal ao rtic aneurysm, with a haema toma accumula ting in
the retm per iton eum on the left side.
NB Clea r ps..lilS margins do not pnw e <In an t'urysm is not leaking if there is
cltntcalevidcnce 10 the contrary

' 24
 Aortic aneurysms conl;n....d

NB Calcified lymph node

;:o:;~.:-'T.,~, _ ~'......
'\0. ..' ( • ,

Fig. 6.4 - This is the abdominol X-ro y of 0 75-year-old woman odmi ffed with
severe abdominal pain andbackoche, The patient wos in 0 stoteof shock with a
rapid poise ond low bloodpressure. This is a leaking oortic oneurysm. rNB the
hme 01 the lopof the film . This ;s the sign of a veryill patient}

125
 Aortic aneurysms <:o<>,inl.'ed

7 leaking aortic aneuTysm

tool for:

• A retroperitoneal rna....effect with oblilL'fdtiun uf the F""'-ld." muscle on one OT

eithe r side
• Obhteration of one (IT (ltht'T OT both renal ouuroes
• Displacement of lidney..
• Displacemen t of the aorta by the haema tom a
• lleu.. in the gut
• Lumba r scoliosis
• The aortic ant'urysm concave to the side of the leak which it..d f ma y or mdY
nol be visible.

Urgent ultraso und , or prd('r.lbly spiral CT, ..hIlUM be ca rried out if there is time ,
Non-urgent dnl"ury"m.. should still be seen quu..kly by a vascular "UTl!;l;'l.m for
further advice, d~ding on their ..ize. TIlt' prublt'l1l has then moved bt>yon,j
thl.' realm of plain films . Smallerall€'Ul}'sm" can be monitored t'wl')' Ii IllImth.... by
ultrasound .

Other an eurysms: iliac/splenic/ renal

Although a hig h indt'''' of suspicion must be maintained for abdomina l aortic
,1Ot'urysms in ord er to lil' II'CI the m , JIll'urysm.. in othe r ve..-els may ,1150
{l(CilShm,ll1y be seen.
Look for (Fig. n.5):
• A bico nvex calcified rna..:-distal to the left or right of the point uf division Ilf
the ao rta .II the inferior mdrgi n of l 4
• Continuation of any aortic anl.'ury..m di."l.dly, a." here, into expanded iliac
n"'-.I'ls . This l'" often 170'H IhI> case , but 111,>t always ',0, and an iliac <U1L"l')'
atlt'UT\·...m can t.'\i..1 in i..elation.

Reme mber- Although k..... common than abdominal aortic ,1Ill.'Ul')'''rru.. iliac
art ..l')' dnt'Ul')'Sm... can kill ~'tlU if tht.-1· ruptun-. The didgllllSis is fl'ddil y con firmed
with Doppler ullrdSllUnd if IOU much bowel gd" dot'S nul intervene, or by CTI
CT dngingrJphy. They <ITt' amenabl.. to stl'olin/!; (If .. urgical repair.

126
 Other aneurysms: iliac/splenic/renol continved

Fig. 6.5 - Huge Ieit iliac orrery aneurysm A 65-yeor·okJ mon X-rayec/ for-
abdominal.??in in whom en abdominal aortic aneurysm wos found bulging to
tile right of the spine. Another calcified moss WCIS n01ed in /he left side 0/ /he
pelvis. mis is on iliacartery onoory5ITI.

127
 O ther aneurysms: iliac/s p le nic/re na l ~ontin.,..j

Splenic arte ry a ne urysms

Look for (Fig. 6.fi) :

• Thl'ldt/right marker, It b very t'a~y when putting such films up III assume
the patient h.l~ gallston'.... on the righI, wht'rL'.I'" these l,,,,,ions .HI' on th,' lett.
ChIodo the l/ R marker on e\"l:'ry film ~'ou look at and Jon't put it up th"
""nmg w ay round
• One or more circular or incompletely circular calcified m.h~ in theleft upf't'r
quad rant
• Splenicartt'r y colk ifk,ltion. This m,ly or molY not be present.
Spll'nie .u lery .lnt'urysms tend to N' discovered incidentallv nn lh" X-rays of
cldl'Tly f'illit'Tlt!>, and are tju- second 1110st common kind of ant'urY~1ll found in
theabdomen, with about two-thi rds contain ing rnkification. They molY also occu r
in yllung women and han> a tendency to ruptu re durfng prl'gn.mcy, with a
ditfl'll'ntial diagntl'>isof a 'ru ptu r edectopic' and a high Illllrtality. They <11-e usuallv
asymptomatic and Idt alone in the l'ldl·rly, butthe opinion of ol va....-ular surgeon
l1Ioly be sought. They mav also occur in portal hypertension .

Renal artery aneurysms

These all." ran' and usually an incidental fmding on imaginJ;. but around uru- in
five isbilateral. They m.1Y be .ls.... lCidl,'I.l with hyp-rtenston, pain and haernaturia,
and must N' d iffl·n.'nliat,'I.l from renal calculi, g,lllstont.... etc. as tht'}' presl'nt ,1'"
cakified rounded opacnte, in the l1.mks.

Causes of anl'urysm s
• Artt'fio'-;CI,'rosis
• Hypertension
• Infec tion (mycolic)
• Trauma
• Congl'Ilital
• Fibromuscular d ysplasia
• Polvartentis nodosa .

\"8 Th.. plain film detection nfan ,lnt'urysm will USU<111y 11'.lU to urgent further
'higlH K h' inn.... li ~.ltio ns In con firm its pn"Sl'I1Ct' .1I1d extent, but the abse nce of a
visible dnl'U I)"sm on plain fil ms docs not mean the pati ent has not ~ot one.

129
 liver calcification

Calcified lesions in the liver are relatively un common bu t occur from time to
time. Of those that do, representative causes include:

• Old gr,m u]nmas (TB, h i~t{lpl,l s mosi s)

• Primary live r tumours > hepatoma
• Secondary liver tumours, e.g. colloid carcinomas from the collin, O\"lry or
stomach
Hyda tid cysts with fine lines or contracted 1'l.l gl'S if partially collapsed: the
'water hly' sign.

Calcified g a llbladder. ch ro nic c ho lecystitis

Occastonally the gallbladder itself may calci ty - ' porcela in g,lllbladdl'r' - or the
hill' within it maybe (If high density - 'timey bill" -c both these rht'0I1mt'M being
associated wuh chronic cbolccysnns.

Fig. 6.7 - A 59-year-oldpotientwith /ine stippledcaki fication in the liver. This

was secondary tIImour froma colloid carcinoma of the colon. Note the ossocio/ed
elevation of me right hemidiophragm due to liverenlargement.

130
 Splenic cakmcation

Calcification in lht' spleen is an OC'C<1"'inn,,1 and usually Incidental finding on

abdominal X-r,l}''''. It mol Y \'dry from oneor two specks of calcification to lal');t'r
ma",~ occupyinl'; almost Jl1 of the .. n uself.
~plt,

Cau<,('s
• Cysts tcnngenital, pe-t-traumatic, h~ddtid)
• Cranulorru (old TB)
• Phlebolith» (h.ll'm.ln~iom. l)
• Infarction
• r.u asilt'S(Anllilli.frr an/lil/alu,,)
• Sickle rell anaemia.

Fig 6.8- A 50-year-old woman. Incidental finding ofcalcified mass in spleen.

This was a benign cyst bul note ,he big liver.

131
 Calculi

Renal calculi (Fig . 6.9)

The majority of stones (1:l5--9()%) that form inthe kidney s are radio-opaque, owing
to their calcium content . They ma y ran~e in appeilrann' from multiple tiny
opacities (nep hrocalcinosis) to one bi)'; opaque stone comp letely filling the
collecting system (staghom calculus).
The plain film problem consbts of proving that an opacity mai ntains a constant
position in relatirm to one or other kidney by oblique films, erect films or control
tomography, and diffcrennating between punctate costal cartilage calcification
and g<lllstones, both of which are anterinrl v placed structure s, whereas kidney
stones are posterior, Large stones m<lY tit' confirmed to be posterior and therefore
renal by <'I penetrated lateral view, even though they overlie the spint'.
Other conditions, such as lB , cysts, tumours and renal artery aneurysms.
may be associated with calcification, and nnn-opaque calculi can abo occur, e.g.
uric acid stones in gout. Renal stones may, sometimes, be demonstrated non-
invesively by ultrasound and CT.

Some causes of renal calcu li

• Hype rparathyroid ism

• Infection
• SI,lSis /obstmction
• Dehydration
• Hypervita minos is 0
• ~1edullary sponge kidn ey
• Schistosomiasis
• Gout (uric acid stnlll'Sl.

132
 Calculi conlin"""

Fig. 6.9 - AbdominalX· ray. S/oghorn coku/us on leftside. The righl one;s as yel
incompletely formed. Th,ue can be treoteel by shod·wove lithotripsy and
percutaneous e.trodion methods of interventionol radiology.

133
 Calculi conri"ued

Fig. 6. 10- Nepftrocokinosisin righ,/CiJney The left kidney hod been removed.

134
 Ureteric cokuli

• In p.llit'nb who prc-ent with suspected renal coltc the hunt is on 10find the
obstructing calculus. R.1n'ly other 11'Si!l11s, SUChdS a sloughed p..lpill'l or blood-
d ul may cause obstructive sym ptom'>, but first and foremost ynu a re !I}()king
fora small calcified llpdrity in the hne of the ureter,
• Cynics will tell you that ,111 you can SdYabout the ureter is th,1I 'il goes fmm
till.' kidney to the btaddrr", LI'. it may he tOftUOUS, dilated and Pl.topk (and
Ihb i.. truel, but the usual cour....• is out of tht' kidney, up onto till' F",0.1S
muscle, along theline of till' tips of thetransverse pmu'S,*'Splus Of minus a
few nulhmcrrcs, down over the pelvic brim and SI ~lin ts, round parallel to
Iht'lateral aspect of the true pelvis, then mloJia l1y into the bladder above the
level of the Ischial spmes.
Crucial fact: If you see such an opacity in a symptomatic patient do not a..sum e
it is an obstructing calculus, as many phenomena can mimic such a stone, e.g.
costal cartilages, calcified lymph nodes , pelvic phleboliths etc. You must then
request excretion urography (if the patient is not a lll'~ic to ro ntri\st mediu m]
(al for the r'ldiologist to pm\'{' whether or not the OpJcltyis an obstructing ageut.
(bl toconftrm thelev el and constancyof Ihl' obstruction by serial films, and (e) to
c onnrrn whl'thl'r or not the obstruction is complete.
The level will then dictate the management and approach to intervention,
shoultl this be required.
Remember. Emergency IVUs can teke many hours to complete if tht' kidney
is severely obstructed, because (If delay ed excret ion . The exami nation is nor
complete until the level of the obstruction is established.
Thereare three main positions where ureteric stones art.' especially likely tu
ol>«truct:

• Thepelvturctenc junction
• The pelvic brim
• The ureterovesical junction.

What about allergic patien ts?

Renal ultra....umd may show a dilated collt'Cting system, and an ultrasound (If the
bladder may show J 'ureteric jet' of urine from the affected side, thus excluding
obstruction of th,lt ureter. Control IT scans of the abdomen may show oedema
typical of an obstructed kidney and a calculus in the lov..-cr end of the ureter on the
sameside, thus avoiding contrast medium.

135
 Ureteric calculi con~nuM

M eg~ hi n l: Ii shm..m an [VU film in an exam always ask til SI;'t' the control film:
this is. d film of the abdomen taken ~'fnl\' any contrast medium i~ ~i\'l'Tl. This
will:
(a) Ensure that you do not miss an of'dqUI' calculus , which may 'disar f't'ar'
completely after contrast is given teven a complete sreghorn calculus), eo you
will not see it (see Figs 6.13 and fI.).I);

fig. 6. , I - A 46-yeor<>/d man with left renolcolic. Nole!he /'wo opocitoes in!he
'eft side of !he /rue pelvis. ?colculi.

136
 Ureteric calculi conh'"ued

(b) Impres s the examiner and conH'Y the fact that you understand IVU
exilminations and ju,,1 t'llilctly what you art' trying 10 do .

Even if you art' not shown a control film you w iII be giVt"fl credit for asking
for it
:'\8 A trainee rddiologisl in a radiology exam might be failt'd for nvt obking to
_ a control film, .;0 this is a most important concept.

Fig, 6.12 - Same patientafter canlrasl, Nate /hehydronephrasis and dilatedleft

ureter down to the /evel of
the opacities, confirming tha' these were obstructing
cakuli.

J37
 Ureteric calculi I;o"'i,,ved

Value of control film s.

Fig. 6. '3 - 3O-minufe poJkonlrostfVU h"lm Jhowing opparenl large right Jroghom
calculus ond normally excreling left kidney.

138
 Ureteric calculi conli"...d

lytic
0000
lesion

Fig. 6. 14 - Control film onsame patient beFore contrast, showing only a smaller
obstructing calculus at the right pelviureleric junc/ion and cakareOtJs debris in
the inFeriorcoly}(. Note also the lytic lesion in the left iliac bone. Th ispotien/ had
disseminated meresratic disease andhypercalcaemia, predisposing 10 renal slone
formalion .

• TI\l.' interpretation (If a post-contrast film Tn.1Y l>t. \'l.'ry different after its control
film is seen.
• Bealertto the unexpected incidental finding and look right rou nd the film for
lither abnormalities .

139
 Bladder calculi

Stones in the bladder an- relatively rare. They can N' either larg" and solitary t'.Ioi.
the sill' of " hen's egg, nr sma ller, multiple a nd faceted. They may ilPp l'.Jr
fortuitously in patit'nts betng x-reved for other purposes. or be found in the
bladder in patients btoing sp'-'<:ificall~' inn·stig,1tl'l.l for urinary tr,l'l problems
(d ysu ria, hacrnaturia etc.I,
Look for:

• A calcified object lying in thl' midlinl'. In thl' supine ptl!'ilio n with a It.1 tlf
urine in the bladder a heavily calcified stone will move tu the dependent
position, i.e. the postenur concavity of the hl,lddl'r.
• Mobility. [f you rl'l1ut-st right and [l,ft decubitus films mobili ty ttl the righ t and
left dependent p-lSitions in a full bladder within its molJ'giTls "ill confirm J
bladder calculus (an ultrasou nd l'll.,lmin,1liun would, hOln'wr, be preferable
10 "void Unnt'H"S",uy r" d i,lt ion).
• Remem ber that a r hnmtcallv Inflamed bladder may be contracted rou nd a
stone .1nJ the patient unable 10 achieve bladder filling , precluding
demonstration (If th is phenomenon.
• A blad der stone mJy ,KtuJlly be in ,1 bladder diverticulu m and therefore both
eccentric from the midli ne and immobile on decubitus films . Further irn.Jging
lt'Sts would be nl'Ct'SSdry 10 confum this (IVU, ultrasou nd . CT 11c.).
• Occastonally a pelvic kidney can con tain slonl's a nd fUIII you in to
misdiagnosing 'bladder stones'.

140
 Bladder calculi con ~nlHHi

Fig. 6. 15- Bladder calculi. This patienl hod hoematuria anddysuria

141
 Ureteric/bladder calcification

Somethi ng to be dls nng uis hed fro m lum ina l calcu li in these st ructures is
calcification in the walls of the u reters and /or bladd er. This is a n' ldliwly rare
phenomenon in UK patients wit h causes such dS pos tradia tion cystitis or
neoplasms, but a \ .t>ry important dnJ commoner radiologicdl finJin~ in certain
other coontrt ..... where schi...to..,umidsis is endemic . Bladd er calcification require,
10 be differentiated from calcified fibmid.., occupying its ptlSitw'\n and prostatic
cdlcif!caliun in It, base,

• Nt't'plasms
• Pos tr sdano n
• Tubl'rrolosis
• 5chistrl'.om iasis
• Amyluidnsis.

142
r Ureteric/bladder ca lcifica tion COIl~n.-l

Fig. 6./6 - CakjfieJ risht urelff A case 01 right·sided tvbercvlous

aulonephrecromy with calcification which has progressed down the right ureter.
Nole olso the old left psoos abscess/roding down to the lefthipjoint, which has
been enteredandbeen parliallydesrroyed bytuberculous disease from Ihe spine.
This 0150 gave rise to a 'cold' abscess in theleft 9,oin. The disease on theright
was arres,eel before il reached thebladderwhich didnotcalcify.

'4'
- Prostatic calcificotion I'ca lculi'J

• In men dgN 50 and over films {If the abdomen and pelvis may b...-gin to show
pu nd.l l ~· I'p,ui lit", ,l r~'!l'dring N'h ind an d above the sym physis pu bis. caused
by calciflcnton in the pW!!.I<1II'. This l1lJ.y be a...",Jctillt-d with infection, but thi..
to. ntlt usuallv thl' [.1"'1' , It IndY be fint' (>I' coarse and ocrupy only part1>1' allnf
the gland , "'II is nul d reliable predictor Ili prust,'lk size.
• 1'nl'.t.llk (,llctfic,lliun is Mt pn-,(ilnn'wus in il~.'lf. but it dlll.~ nllt exclude
m,dignolncy in anoth..r part Ilf thl;' gland. ThO' main differentia l I!> from d
urethral ca lru lu.., which is u..uallv midlillt." in f'O"ilion. uniformly den-e.
..mooth and ....lI1ldry Do not mistake the en-face soft-tb..ue ..hadow III Ilk-
·t·
peni.. for a cdkifil'\i bladder shmt', rn~t.ltl' OTureth ral stonl' (.... Mi..l.·JlhnK
imJgl~ and drtl'ldl1.., pd~e 17M.

Hint: De not mi..tdkl· d melnng <,uppo-.illlry in the rectum for prostanc

ralrifirarion!

144
 Prostatic calcification ('calculi') CCI1lifl-J

Fig. 6. /7 -An example ofcalcification in thepros/ale. Nale also the phlebolith

adjacent to the left ischial spine.

145
 Bilier cekuli

Since only around 1O'k of biliary calculi are visible on x- rays, this is a pon r way
of Junking fur them. I ~ patients who are clin ically though t to harbour them,
ultra ....umd is therefore by far the preferred initial method of in\'l..,.ti~ltion , and a
neganve nlm certainly doe, nol exclude them . :-.:~...e rtheless, patients will rontmue
to pn......-nt with opacities 01.. an incidental finding in the right uPf'l'r quadrant
requmng danncanon and cera..iondl1;.- a problematic ultrasound e\.J.mination
ca n be rlanfied with a plain film,

146
 Biliarycalculi continued

Fig. 6. 18- Aclusler of opocities intheright upper quodront in 0 middle-aged

woman. These oregollstones.

147
- Biliary calculi con~n.-l

Fig. 6. 19 -Anotherpotient withgallslones inthe cystic dvctand bileduct. Note

the Riedel's lobe e)( ~nding over the righl iliac crest (see p. 35).

148
I Look for (Fig. b.l':l):
Biliary calculi conlinued

• A singll' opadw or clus ter of llpad til~ in the RUQ or right flank . Gallstont'!'
rna}' be single or multiple, I.l rgt>or wry small. Their appea rann- may be
\'t.'ry variable
• Evidenceot a laminated or fMrlt'd structure, i.e. concentricrings llT polygonal
~pt'S Jut' to abutment of stonl;'!; one upun another
• hidffiCt" of co-tat cartilagt' cakification/l\"ILJl stone formation on both sidt'"
of tho! abdomen which may be mistah'fl for bilidry calruli ..... hen seen on the
ri,l;hl. But remember that renal and bil iary stones can coe xis t, dod the
gallbladder Ii6 in frunt (If the ri~h t kidney.

Gallstones

1A9
 Biliary calculi cor>h"u«J

Help ful hints

• Ask for d prone ob lique right upfX'r quadrant view. This will often Isolate
calcuh in the gallbladder, especially if they art' near the spine, and abo cut
down scatter from J full abdominal film, giving beucr clarity and contrast.
• Look lower down than just the right upJ"-'r quadrant. The gallbladder mdY be
low-lying bccauseof ,1 big liver, or b eon a wry lung cysticduct , Occastonallv
it m.1Yeven lit' in the pt.'lvi;;,
• A lateral view may help, as gallstone, will tend to lit' anteriorly and kidney
stone, posteriorly, but the film must N' suffkil'ntly penetrated.
• An erect abdomina! film m,ly caus•.' small calculi III undergo 'I.lYl'ring', i.e. til
form ,1 small horizontalline as they flU'll in the bilt', The gallbladder m.lY be
contracted, however; and prevent this fmm h.lppt.'ning if dL"'t'<1....-d or if the
patient has just ...It e n,
• Remember that SOffit' stones are UII the edge of visibility and by nil means
obvious and the V,lSt m,l ~lr ity (4(J'l ) an- invisible ,my way, due toa I,Kk of
calcified content.

These techmqce, may N' helpful in dernonstratmg bih<1T)' calculi.

Pancreatic calcification
Look for (Fig,6,20):

• Fine punctate foci of calcification lying (rom the right of the uppt.' r lumbar
spine p.t...sing upward s and obliquely to the left to the region of the splenic
hilum,

g em embcn

• Thi" m,1Yno. wry f,lln! ,Ill.! difficult to ...... '111 plain film" and may only show
up on ultrasou nd, or particularlv CT.
• TIlt' absence of \'isihll' pancreatic calcification doc-, not exclude chronic
pancreatitis.
• Cakiftcation of the p.lnrrt',ls m,ly also orru r ill cysuc fibro'iis. and Ol:C,I'illlllJlly
with tumours.

150
I Pancreatic calc ification conri~ued

fig. 6.20 - CalciFiecJ pancreas [umbor spine film . Middle-aged mon with long
history of alcoholism presenting with recurrent bouls of abdominal and back
pain. This is a calcified pancreas, indicating chronic pancreatitis.

151
- Calcified lymph node,- again

See Figure 1.U'. Incidental finding (If extensive lymph node cah-iflcatlon, cause
unknown. Noll' the potential diffirulties if louking for coedstom renal Of bili'lry
calculi.
Because one (IT two calcified lymph nodes are S<.l rornmon lin abdominal X-
rays they ere u~ually regarded as inert incidental findings without current clinical
significann>, but there an- de finite pathological G1U~"S.
Remem ber.

• Hislupl,l"mosis
• Filariasis
• Lymphoma (f'\1S1tht'rapy) - t'Spt-'Cially retroperitoneal
• Calcifying metastases <thyroid, rnlon, osteosarcoma (riln·lyl.
Megahint : Ma ke SU Tt' you know whether O T not the patien t has hold ,1
lymphogram within the 1,1SI year, ,IS this willlead 10 pe rsisten tly pl't1cifilli but 110/
calcified lymph nodes in the retropen toncum , althtlugh they may look the same•
•swi ng to n-taincd contrast mediu m. Th i!>. however; will pnljo;n'!>siwly disappear
over about 12 months hut Iymphll);r'lms are roUdy done in thl.' UK these d'I}"S.
II is p ara-aortic and paracavalnodes thdtOP.lCify at lymphography, t.e. onl y
tho..e over and adjan'nt to the spin e. Thos e further out <He usually in the
mesentery, hut mesenteric nodes can ..tilllie over tfu- spine.

The adrenals

The normal adrenals ,In' not vi..iblc on plain abdominal X-r.1 ~ . ... nd tumours of
these stru ct u res are on ly visible when significantly enlargt...l OT calcified.
P,l li,'nts with suspec ted adrenal disease should ~ll din'elly til ultrasound, CT,
\I RI or red ionuclice imaging. Ca lcifi, -d ad rt'U.lls on plai n X-rays mean Iiltl.... in
terms llf di,lgnllSis. ...s mll.,1 patit'nb with calcilir-d,ldn'flals do !llll have Addison's
d isease, and vice \'t'J'<;J . Nevert hek-ss, it is instructional til n 'c-ognizc th,'S., for
what they are an d to un derstand the causes.

152
 The odrencls continued

Fig. 6.21 -IVUFilm. There isfaint excretion of con /ros/ medium in thecol/ee/ing
systems. Ineiden /ol finding of bilateral adrenal calcification. The patienl hod no
relevanl symptoms or signs.

Bilateral adrenal cakificolion

• Hil('m(lrrh,\~t' tncona tal, perinatal lIT l,l lt" ), eg Wa tl'rhllu~' - Friederich-en

syndrome
• Tuberculosis
• Histoplacmosfs
• Amvloid
• Neopl.l..m, e.g. gangliom.'UnllTld, carcinoma
• Phdt'tl("hnlflll.-;,· loma
• Wolrndn's di~',l'-t' Ifamilial \ otnthtllThllO"bl
• AJJi....-n'... di .....·aS(' (Tall'lyl.

153
 Cater 7
The female
abdomen
Ap.lTl fro m its d isti nct bon y co nfigu ration bt·jng wider for tht' purptl!it.'!' of
childb irth, (wl,l in path ologica l entities unique to the female pelvis may p reen:
themselves on plain abdominal x -r.ws. TIlt'SI' cons ist pr imaril y (If masses with
O f wi tho ut calci fication, tilt' config uration of the latte r w hen prese nt USU<11Jy

helping III nar row down the Ji,lgnosis.

NB The l MP at any woma n of childbe aring age sho uld be k nown before
sub jecting her to irradia tio n of the abd om en . It sho uld also hi' known 10 ,my
observe r who att empts to interpn-t any female patient's X-r'IY. vcey rarely woul d
,1 pregna nt abdomen be dl'1ibt'r,ltd y X-TaYN - t'.g, after trauma Of it 'one- shot'
[VU. Tubal di~ /or dir-eolll,lining vaginal l<1mptlnS may ind ie.lIe thai the pa tieru
has been stenllzed or is undl'fKoing the current lMP, rbpt-'ctiw\y. The qUNion
'Do you think you could N' pn'gndnt?', n-'luin'S ,1 firm nt'/oi,lliw before 1.1l..illg
,my X-rdYs.
Remember that one abdominal X-ray equal-, 21' chest X-rays or "i' and a half
months of background radiation dose.

Caus es of mJs ses in the female pelvi s

• Voluminou s bladder bonw women «Ill hold up In 2 1i Ifl'S)
• Enlargt'lJ u terus (look for fl'l.ll parts /rht-'(k LMPJ,consider haomatocolpos in
a yllung female ch ild
• Uterine libnud tcatonen (~'t' Hg. 7.1)
• Ovarian m,l"St'!'. Benign cy ~t "/ n l'orl d s m " - may become w ry largt' .md
calcifv
• Haematoma tatter trauma!
• A~l">S (pos!tlpt' r,l!iw ) - 1(1('1.. fur pl)(kt·!s of gJs
• P~lCTJI rneningocoeh-.

154
 The female abdomen co"'i"uoo

Fig_7.1 -A58-yeordd womon with a hugecraggy moss palpable in /he lower

abdomen. The X-roy shows heavygranular calciFicalion. This is due to multiple
odiocent uterine fibroids .
No,etheincidental Finding of gollstones in the right upperquadrant.

155
- The femal e ab dome n COIl/,".....d

TIll' prl.'ft'moJ initial method IIf inve..hg,ltion l,f J pelvic m<l~" in fernah-, is by
ulrrc-ound throu~h.l full urin.lI'ybladder, Trdru.\·d~l1dl ultrNlUnJ m.t~' latl'f be
used .h dimcatly indicated: thi..doe, nol require a full bladde r.

Wandering fallopian tube clips

Fig 7.2 - A woman of childbearing age in whom Ihere hod been severol
unsuccessful ottempl$ at sterilization. If ultrasound connol locote them,
conventional radiography moy s/ill be required wilhdue regard 10 !hepossibility
of pregnancy.

156
 Cater 8

Abdominal
trauma
Ireuma to the abdomen may have important TadioJI1);iCiII m.mif~t.ltion.", which
it ill important to know about. The-e coin 1::>0.. d ivided into p'-'Ildr'llin);; injurit..., "'1\h
<l~ knill' Ill' gunshot wounds 10 solid OT hollow org,lns, OT blunt impact trauma
'otKh as molY llCCUT in road IT.llfir <1fddenh. In tht""l.' lat ter days ot surgl'ry and
intcrventiunal r,ld iol0l':;Y i.l lw gl'llic accidents may aho (occur within theal....Jonwn,
'lO that x -revs m,ly be required 1(1 look for t'\'l'rylhin~ from m.l1pusitil>nt'd "h'nb
to retained swabs or forceps after operations.
t\l'\"l'r think til abdominal trauma in Isol.uton and 10the exclusion of a ll l'ist>,
but always as just one .m ',l of wh.lt may wd l be a mu ltiply injuTI...t pa tien t:
CIInwl"!'dy, if iI head injury dominates the d ink ,11 picture, ta ke full account of
tllat bul do not fllrgt'l to consider tb at the abdomen an d chest m.lY haw been
injutt'l.! ,h \\'(']1. Stll",amint> both c.I rd u ll~v and. if 1Il'n 'Ss.U') ', !/;t'l them both imaged.
An early triage of the p atiem will of COUN' be m'(t"'~ry to de termine thl"I'ltost
seqUl'fK1.' of im 't'!>ti!/;,ltiw procedure, but each trauma centre will h J W its ow n
protocol.
In evalcanng x -rays for abdommal traumalook for:
• The p,llit'lIl'S name. Establish ,b quickly olS po..~ibll' the p,l tient'~ identitv fnr
bothmedical and medico-legal reasons. Unconscious casualties m.1Y initiallv
have III be labelled .1S ' unknown' or ' Mr X, Get the name on the films as
soon as possible as mu ltiple 'unknowns' nld~' cudden jv flood in, e.g. after J
major molorw,ly accident or rail era-h. lm din!/; 10 potential mix-ups,
• The lime of the film h',g . lJO pm t. Multiple '#.'ri,ll X-r,tys molY be required
following admiss ion ,1111.1 the subsequent tempora l sl't1ut'nce milY be
importa nt in follow ing events. ,101.1 thl' .lollI'S on ,111 the films willbe the s ame,
unless thl'Y cruss over midnight.
Also
• Chec k what is left and right. Do not mista ke iI norma l liver for an injured
spleen by failing to do thi .., or miwi,l!/;ntl'>t' !/;as under tht' ' rig ht; berm-

157
- Abdominal trauma «lII~nlldd

diaphragm from seeing it normal ..tcmach Oil ,1 film you h,1\'1;' put up h.ld. to
front. (Null' how frl'lllwn tly they dolhb Oil medical TV "'Mp", ,10<1 ,'\','11 reat
medi cal p~r.lmml'S - occ,l.,ionally even UpsiJl' down! )
• M,Il..e gOlld uscof the chest x-ray, which will almo.. t rertainlv haw b-en taken
.IS well ; if not , then request one. The, m,ly help to resolve co nfu sing Uppt'r
abdominal findings. (If both recent OI1"l'I and prl'-l'xisling Jbt',ISt',.h well ,I"
ils..i.,tingthe .In.ll..,t hl'li..t pn·I,IJ'l'T,'lin-ly.
• M,ITt' than ever now is the time In look ran-fullv ,It the skele tnnto check fur
fu cluTe'i and d ispla ce me nt 1' ( h\'ny stru ctun.... The cnn firrnatkm Ilf such
findings will indicate the -everuy (If injury and the likt'ly lITg,ms involved .
e.g. ldt lower nbs: ~pll'l'n; and pelvic bon es : the bladder.
look for.
• Free gilS in the peritoneal cavity. This will indicate It\\.' rupture (If il hollow
viscus ora pml'traling injury 'If pM I of the I;u\' inJic,}ting the nt'Ct'ssity for
urgent surgery. 1J0 not f"rgt't Ih,}1 colonic interposition and other pht'nomt'nd
m,ly mimic a pneurnoperitoneurn, but look for the 'double- wall sign ' (st't'
P.lgl' R'l) as I'll'll as for air under the d i,lp hrdgm . Remember: seriously ill
poltit'nts m,ly not be fit for erect film~, in whic h C,l st' ,1 ll'il or rij;hl decubitus
vtew m,ly be attempted and free /;i,ISsough t in the flanks, but all the didgmJ!;tir
wo rk-up may have to hI' done on supine films alone if lhl' patient Is nul fit
even for this, so familiarize ynursdf wit h Iht' sup ine m,m ift'st,ll ions of free
alr for this eventuality 1St'!' ....ction on pneumoperiton eum, p. Ii':!!-
• C ,l.. m the I\'lr"f'l'ril"nt'um, (So.'l' ChJ ptt'r -I, p . 100). i\ stab in the back or
rt'tl'l,lpt'rilon",ll ru pture of lh(' bowel m,ly occur without visible air in llll'
pt'rit,mt'JI ravuy, UJI, II.. for irn");ul,}routlim-s oi d ,nl.. air dl'nsitil~ around the
fNl.-ls O1u....·I,">, kiJ lwys and diaph r.rgr rutlc mJ rgins.
• Appan-nt enlargemcnt of normal org.lns ..uch as the liver, splt'l'n and lidnt'ys
- this m,ly indicate subcapsular h.n-matoma formation nr ,'\ '1'11 rupture of
these urBans, " Spt-'ri .l l1 y if th..ir no rma l outlin..s have been lust. Such
colkcttons can bt, mols.sin' and ran bt· Jia);nnst'tl hy displacement of the bmwl
Irom lark of normal ~dS in tfu...... IOI'.lIinns,
• Loss of the fNlolS ma rgi ns. When this is seen in the context of trauma it is
likt' ly III I\·rn.....·nt a m,lS"iw retn'pt'ritont',l! haematoma, inJicatin~ Sl'wn'
in jury ,md bluud 111ss. Ll1uk for fr,ld u~ in till' lr,lllSWT'Sl' rrx)(t'sst">, Sl'Hliosis
1'\lI\C,l\"1' totht' inju rtoJ sidl', ,111.1 e\"id..nn' ni btul )' injuri~ in tht' Ill\w nnlJ!;1

ribs.

158
 Abdominal trau ma conli,.1lftd

u • Be aware that trauma can cause secondary ileus and a l,lrgl' accumulation uf
ga~, which call int~rft'I\' with trauma asses..mcnt.
"
• Dispbn'ml'nt of holh ....v organs, ",.g. the stomach med ially ,\IlJ down ....',mls
n with an l'nl.uging spleen, or upward displacement of small bowel loops nut
of the rl.'1vis with a ruptured bladder, Check abo for an overloaded bladder
,
"

and catheterize the patient, if not ,'llft',ldy dune, III rdil'w Ihb and monitor
F"-I!'>~ihll' h.remaruna and urine output sub~'\jut'nlly.
r • Flll\'i~n bodies, "'.g. buill'!" in the USA and lither countries where gUll!> <HI'
l'rl'\'ly available.

Cruclol Ic cts to remem ber

• A normal initial X-r,ly doc, not exclude sign ific,m! intra-abdominal trauma,
• X-ray,;.ln' iu:-! one mod'llity in the im,l~in~ armamentarium used in Irau nM,
aJthlllli:h in s-ome parts of tht, world tht'Y may be the Imly1I11i'.
• Urgent and ""uly ultrasound - or bet ter, CT -cmnmg - m,ly bepreferableto
Sol\l' time in critically injured patients in evalu.utng, for example, the liver
and spleen, and remember that del'lYloJ rupture of the splt'l'n in parlkul,u
can occur. Injury to the p.mcR'a" le,ldin~ to traumatic p.mel't>,lIitis m,ly often
be unrovered hy CT, and colour Doppler aura-ound m,ly conttrm or exclude
j.ll'rfusiOll of org.-ms and limbs.
• The head , rhl'sl, abdomen and limbs ran bt, r,lpiJly scanned in ,1 sri r,11 CT
machine, although l~st'llti,ll imrnnbihz.ttion/anae-thetic devices m,ly slow
things down d hit.
• f..l.rly rm~I't'SS to evcreuon unwarhy, un'thn~rarhy or artl'riography m,l~'
hi> an urgt'nl and nece-sary follow-nil from plain X-ray" in the cveluauon (If
trauma.
• \ fRI m,ly be urgt'llt ly required to assess Srin,lllrdUm,l.
• 0 0 nol unne cessarily tak e out a patient 's fun ctioni ng kid ney: he may onl)"
have the one, You must make t'H'ry dfurl ttl establish the r~'nn' or
othl'rwist>of another wnrking kjdnev before Idking out tht' only one he or
she h,lS,and rem ember tll.ll kidneys h,I\'I' remarkable ptlwl'r" of rt'gt'nt'r,ltiI11l.
And wnsidt'r this for ,my injufl'll kidnt'y : '\Vnuld l ctill t,lh' out this injured
kidnt'y if I knew it w,l" thl'nnl~' one?'
• 0 0 nol wacte lime with imaging if th e palient is bleed in g 10d ea th in fmn t
of you . Rc-uscttation mu-t come fir-t , and after that in "omt' r,lst-, immediate

159
 Abdomi nal tra uma con bnved

transfer to theatre may be required , and if nl'Cl'Ss.lry X-r,lYs undertaken only

then .u the discretion of a senior doctor.

Trauma : rcpn ned kid ney

Noll' (Fig. 8.1):

• The swelling (If the right kidney

• The t'SCapt> 01contrast trorn Iht, right a,lll'Cting system, indicating rup ture of
tlu- kidnt'y. A I,Uj;I' volume of hh ...Jd is escaping as well.
• The scoliosis concave to the injuft'd side (ind irect sign)
• And most imrnrt,mtly: another normally (,ll.cn'ting kidney . >1\ the opposite
side .

Footnote : Escape of ('onIT.1S1like this can occur in severe rena! obs truc tion ill the
acute setting.or also in the chronic Sl'tting where ill-an form a huge fl'lfllpt.'ri lont>dl
flu id conecnon called <l 'u rinoma'.

160
 Abdominal trauma mnlinued

,f

Fig_ 8_' - This is on IVU Film oJ a potienllided in till! right Ronl in a fight. The
pklinFilm showed loss of the right renol and p500S outlines.

f61
 Abd ominal trauma conhnued

O ld trauma

Fig. 8,2 - APsupine radiograph of on oldsoldierwho'slopped one ' during /he

Normandy ca mpaig n in '944. The leN pubic ring and right sacral wing hod
'0
been smashed by the bvlle', which then tumbled and come resl beside /he
right femur in 'he groin . Evidence of old trauma may occasionally present on
abdominal films ca using confusing bone changes,

162
 Multi Ie in'urie5: thorococbdominol trauma

Lo...k for (Fig. IU ):

• Compl..'ll' '*'p.lT,llilln uf thelower thoracic spine and corres pond ing ribs
• Ruptuwof the It'ft hernidiaphragm with lol'f'dTation from the cht'Sl wall
• Fractures of the urf'l'T nb, and bilateral sUf);ical emphvsema
• Colon in the Chl.'S1
• left N 't,1I pnt'Umolhoral<
• Di~t of IhI.' twart 10 IhI.' righl
• Sandhd~ ~t.IN lizi ng the head .

Tbe child died from o't'.i~it'n t w \"t'n.' ht-ad injun..,...

Fig, 8,3- Child aged 4 years who was thrownoutofocar when ilhilo free. No
seal bell. SuHered severe multiple in;uries andhlled.

163
 Cater 9
latrogen ic objects
Radiological
ln this age (If well-developed intervenhonal prOCNUTt'S in radiology it is common
In see objects that have been deliberately placed in the abdom en 10treat disorders
in most systems. Being able to recognize SOffit' of these for what they are will
enable you to deduce what has been w nlllg with and done 10 you r patients. The
posi tion of these dl;'viCl'S may abo be monitored by plain X-rays to confirm that
they are still in position and h,\V1;' not slipped, leading to malfun r tion .
Typical devices to look for include:
• Aortic/ iliac stents for vascular stenoses - with wire mesh structures in the
line of arteries
• Biliary!urin,lfy /G I tract stents for stenoses - ('l;'1;ophagus/rectum/sigmoid
• Temporary ru-phrostomy tubes to decomp ress obstructed kidneys often with
pigt,lib 10 aid posi tion reten tion
• Abscess drainage tubes
• Inferio r vena cava filte rs Ito p revent pulmonary emboli from the legs)
• Embolization coils/balloons - 10 ablate vessels in tumours prio r to or ,1" an
alternative to surgery, and to shut down pathological circulations.

Retained con tras t medi um

This m,ly also be seen in the appendix or colonic diverticula (barium) and in the
spinal canal (myodill - with round blobs of this high densi ty agent Irom previous
mye1ogr,lphy examinations. It may even exten d right up to the head.

164
 Rodiologicol l;OtttitNled

I Fig. 9 , -Inferior vena cava (1Irer_

16'
Radiological con,inved

I
Stent

Fig 9.2 - RighIexternal iliac $1ent.

166
 Medical/surgical accessories

Ahost (If other objects,lSSIICi<11l'l.l with P.1S1 or currenttherapy or previous surg~f)'

may also present themselves on abdominal x -rays.
Look for:

• Surgic.ll sutu re... or clips, oftl'" tiny and hard In st't' u nless made of d ense
material
• NJ>l.l);dslric tube; in the stomach (usu,lIly with an oPJlJUl' hpj. These ca n cu rl
up in the nose, pharynx or oesophagus, back-track up the oesophagus, or gct
knotted in thl' slllmJch! They INy even be lying down the right or left main
bronchus! Cet views of the head or neck if the tubes han' not reached
the stomach
• Small tlpilrilit... ever buttock am'S tprt>\'iuUS bismuth injt'ctions or crysldllint"
penidlltn for VD tote.)
• ECG IN,h - Uppt'T dbdoiT\l;'n/lowl;'l' chest
• Wire. from TENS machines It) control pain
• Cutaneous p.ltehl... (nkotine, hormones ctc.)
• Ventrirulopcrilont'al ..hunls (hydnlCt'phalus)- don't misldkl" for M"'Ogd'iotriC
tubt-s! Tht-yotten lie over the medial lung fid.h dOO all' outwith the stomach.
• Syringe driver tUM (morphine t'tc.)
• P.:ICl'miIM'r'io
• Tantalum gewe [previous surpcall'l'JXlif'io - gmin /umbilicus)
• Pt'S~ry rings - uterine pmlap,e.
• Fallopian tube eli£,!,
• Radoacnve seeds. t'.g. in pelvis
• ~ll'lill hip pro-thee-, Itum previous fractures 10 the TK'Ck of the femur
• Prosthrlic heart vain... - stlmt1iml'" visible on upper part of abdominal film-
• Umbilical catheters (childn'fl)
• Bladder catheters
• Intrauterine contraceptive devices (pdvis)
• Rl'Ct'fltly ingt.."tl'li pills.

167
Medical/surgical cccessones COfIl inued

Fig. 9.3 - This potient hod very srrong steeisullJres putin For an anterior abdominal
wall incisionalhernia.

168
 Medical/surgical accessories conlinued

Fig, 9.4 - Mtxe 'wrgical lootsreps'! Tontolvm gauze used 10 treat a II'f:fItroi hemia.
Sometimes it con o/so be found in the groin leN herniorrhaphy repairs_ II .breoh
For 0 reIoinecJ swab'
lfI with time. Don't m;sloke it

169
 Cater 10
Foreign bodies,
artefacts,
misleading images
There is no end to the lbt of foreign bodies that may end up inside a patient's
abdomen, and this i;; particularly true of children. Typically ingested objects
include coins, beads. ball bearings, toys,safety pins, ring-pulls, mercury batteries
etc. Some foreign bodies will be poorly seen, e,g an aluminium ring-pull, and
some may be completely invisible, such as a sma ll rubber ball.
It is important to view the child as a whole and not simply the stomach in
isolation, that is, the ears, nose, mouth and pharynx should be checked clinically,
and ..my history of stuffing foreign bodies into ,my other orifices, as well a,
swallowing them, should be sought, ()r even other children's orifices'!
Depending on the timescale it m,ly be expedient to X-ray the child from the
level of the nasopharynx to the rectum in one go, as a foreign body may lodge
temporarily in the lower oesophagus and may be missed if only an abdominal
X-rayis taken.
Later, when the child feelsdiscomfort in the lower oesophagus but the foreign
body moves into the stomach, it may he missed on iI chest X-ray taken later -
only to pass on when it has apparently been 'excluded' but between the temporal
scx.\Ul·nce of the two films has actually ~....-n missed. Due regard 10 minimizing
radiation dose must, however, he constantly borne in mind. But X-rays may be
nl'Cl'Ssary 10prow a foreign body has passed.

\ 70
 Foreign bodies, artefa cts, misleading imcges conllnued

fig. 10./ - Pwchiatric patient who enjoyed meals of mercury and gloss
thermome'ers. Nole also /he razor bladein theleNupper quadrant - these are
usually wrapped in sello'ope by thepatient, but are notvisible radiologically.
The nurses in this potien(s word got into trouble because thermome'ers kept
disappearing. The chest X·ray showed multiple small mercury globules which
hod been inhaled into /he lungs when thepatient crunched /he thermome'ers.

17 1
 Foreign bod ies, arte facts, mislead ing ima ges conhnued

Adults, especially if subnormal, may ingest all manne r of strange objects. and
of course insert all manner of objects into their rectums.
Criminals and drug smugglers lThIy swallow sachets of heroin or other drugs.
or stuff them in their children's soft toys.
Occasionally multiple small speckled opacities may be seen in the abdomen.
These can be anything frum pica (dirt, stones etc.), eggshells, broken den tal fillings.
to lead p aint - the latter having diagnostic sij!;nificance when lead poisoning is
being sought.
Apart from entertain ment value the most important fact to consider with an
ingested foreign body is, will it pass spontilm'ously (e.g. a small ball bearing) or
will it not (e.g. an open safety pin)? The decision must then be made whether to
wait, watch and review (if necessa ry with a follow-up X-rayl, or intervene
endoscopically or surgically to retrieve it. Psychiatric ad vice may also De
appropriate in some cases.

172
 Foreign bodies, ortefo cts, misleoding imoges COt1hnueJ

Fig. 10.2- Engagementring swallowed by yoong child. The insurance company

would nol pay up as theowner 'knew where it was' and so by definition it was
notlost. Should pass sponfonecwsly. The diomonds, being reol, didnol show up
osthey are mode of carbon!

173
 Foreig n bodies, artefacts, misleading images con ,inuoo

Fig, 10,3 - An adult male pre5enting with rectal pain andbleeding, This abiecl
wcs an old'5tyle gla55 radio valve which he claimed fa have 'sat on', as such
patienlsoften do. II wasimpacled disfal/y into theonal mUC05a by it5 prong5.

The main problems are:

• How 10 extract tbc foreign bod y without breaking it or lacerating the mucosa
• Minimiz ing the danger 10 your self regarding HIV, hl'p.'Itili ~, sep ticaernia etc.
• Minimizing the d.mgcr 10 the patient
• Cont rulling your own and your staff's mirth in dealing with such d patient-.
you must learn 10 keep a stra igh t face in suc h circ u m stances, a nd be
sympathetic toward s the p,ltil'nt' s embarassment and plight.

174
 Fore ign bodie s, artefa cts, misleading imoges con,in.-l

Fig. 10_4 - Eldetly potientpresenling wirh rightupperquodrant poin and swpeded

cokulovs cho/ecyshlis. Note the four opocWes in linein the ROO.

• These an- all identical in size , ~hapt> and dt'ltSity.

• GaIl~ttmt'Sall." never ~l perfect. ?Artefact~ _

These turned our to be pandrops in a bag in the p.lhent's pocket! The opacities
had g\Jne a fter the hag o j ~\\"t'(1~ was removed for the repea t film . Note the
punctate costal caTtilaj.W calcitications.
~B The patien t could still have had cholt'CY"htis wi th nOn--opil\!Ut' gallstone,
and stillrequired invest igation .

175
 Fore ign bodies, c nelc cts. mislea ding images COI1tin ued

Fig. 10.5 - Soft tissue shadow of penis simulating a calculus in a young mole
patienr. learn 10 recognize Ihis to ovoidmaking 0 fool of yourself byasking whot
itis on the wordround. Another example is shown in Fig. '.2.

176
 Cater 11
The acute
abdomen
U"~
The most important cau~ of an acute abdomen which It\iIy be associated v.;lh
p1din film Tildiological signs incfude;
• Perforated viscus h-:;pt.'Cially iI duodenal ulcer, but any part of the GI tract
may ruptuf1'I, with ptoritonitis
• Ruptured aortic ant'ury..m
• Renal colic
• Bili.Jry colic
• Acute cholecystitis
• Acute piIllCTt'iltiti"
• Acuteappendmtis
• Intt'Stincll (~tructi(lU
• Acutediwrticulili!'>
• volvulus
• Hernias
• Absce-es
• Vascular occlusion."
• Intussusception
• TOKie dilatation of colon.
00 not forgt'!, however, to view the patient as a whole to take a ch('!ot X.u y
and remember that

• Myocard i.ll infarrtton

• Ba~l pneumonia
• Dis>ecting aorla
• Pulmonary embolism etc. m,ly all m asquera de as an acute abdomen.

177
 The acute abd omen con~n.-J

Remember also that tht' r.ldioll1gical signs may not be present or fully evolved
attbe time of presentation, so if nerr-,"'uy re X-ray the patient afteran hour or so,
or move on rapidly to ultrasound, CT, IVU, angiography or whatever is
appropriate to ~t,lh1ish the diagnosi.. withou t dday.
Ora l water-soluble contrast or recta l contrast may bot' given 10 confirm or
exclude visible t'\idt'nn' of leakage or obstruction in appropria te circumstances.
but thb should only be after diSl"Ussion with the radiologb;t.
Remember also the many cau sl's of acute lower abdominal pain due to
g)'nal'colt>gicaldi!'o(ll\h-r- in women. e.g. dysrrwnorrhoea, Sdlpingitb, ovarian <)-.;t
torsion etc.
Remember in addition to the above common medical conditions that simu late
an acute abdomen tm' other rarer medical ( .l USt'S of acute abdominal pain , such
as porphyria, Addisonian crisis, diabehc crisis. and lead poisoning eec.!

178
 C a fer 12
\
Hints

• Never forgl110 check tht' nam e,m d the da te first and gl't all the other datil
~'OU
can t,ff the nanu- b.hJgt>. Film~ can "d~ily gt'l in the "TOng f"ld.t1~!
• Check male or It'milk
• Check ldl and right.
• Makt' sun' l'n-rything is on the film, trom the bcmidiaphragms to theinguinal
canals, or covered by Sf.'\'t>fal film...
• ~ Idk{'sul\' you under..tand bow the film was taken, te. erect, supine.decubitus.
Of oblique, and 1M! yuu understand the implications of each position and
what to evpect . e.g. fluid levels do nt)l: i1Pf'l'ar on surim' films.
• You see what you Ill1l1.. Ior - don't underestima te the 'mark 1l.')"cNU'!
• In acute abdomens always gl>t a chest X-ray, prdl'rably erect. Remember thai
~ous Chl~1 ueea-e 11'Ld~' mimic serious abdominal disease, and vice versa ,
~OnJdry X-Tdy ch.Jngl-.lo abdominal disease lThly occur in the cbesr.
• Cht'CkIhl! lung base, and luu!.. fur the breasts on abdominal films.
• Find the tee-e, a nd you've fuund the colon.
• Acquire previou-, film!' a~ soon ol~ pu·.siblt' to rompare with new ones.
• ~lol!..t' ..un- you've put rhe film up the right way round!
• Only view films under prtlpt'r conditions of illumination, i.e. on a \it""ing
box, wa\in~ them in Imnt of a window on 01 ward round ....ill guara ntee Yt1U
will mi....20'{ of what there is to see.
• Put a bright light beh ind any area too ddr!.. to eee properly on the viewing
box. Sod's WI'.' will always conceal a sign ificant abnormality in a wry da rk
area e.g. rib frartun....
• Y"U must be abletn exp lain l-'\'t'I),thing yuu see o n a film in terms uf anatomy,
fI<lthology, or artefacts.
• Do not ignoll' <;(lnll'thing yuu do not understand : work out what it is or go and
ask sumt'om' t'I~. who can help you - and in d M' riousl y ill patient, do it ea rly .
• Do not be too proud or self-c onscious tu seek help t>,u ly.
• 'Not hing l'~cl u dt'S ,lilYthing' i.s 01 good working aphorism. Life-threatening

179
 Hints con'inved

iIInt">S mdf be pr~'nt with no or onl y J few radiological ~i~n~.

• R ules Me for the obedienceof foob and the guidilncel1f wise men'. l.c. do not
stick ~liI\'ishly to protocols. Adju ..t f our actions ilppropriJtd y til the patient's
prtlblt'm~, and keep a globdl vtew of the patient at all times.
• when in doubt, do tlK> right thing_lilt' ca lling a radiologi..t at 2 a.rn.
• 'Every woman is pregnant until proved otherwise'. Gt.'t the LMP before
1"l't.JuI...ting X-rd~~.
• Keep en opt.'fImind , Remember the Omcl'p1 of differential diJgnIJSi..,
• Do nilt be boxed in by otht.'t pt.....ple,' "U..f't'CIN labels and diagnc.........
• Le arn to work out the ilgt' of patients from the dpp"'ilTdtlCl' I" tht'ir films (i.e.
fn>m vascularcalcification, dl~l'T'lt1'ilti\"l' "pil\ill changes. curti("althinnin~ times
of l'Pirhysml closure etc.) , and cross-check it with the date of birth and the
date the film was ta ken.
• M,lint.lin J sceptical outlook Oil all d,lta supplied. l;.'lt / right markers can be
incor rect and the wrong names gt'! lin patients' films. 'Check fur An",s error.'
'tour p.llil'nt may deny previous SU!"HI'ry bu t han' Win.' su lu rl'" visible. Have
you got somebod y else's film in yo ur hand, or is your patient demented ?
• Learn to look, th ink and .utku l,lll'/discuss the findings o n X-r.IY films
simu lt,ll1"ously. Th i.. take, m,my YI'.u's to perfect, bu t nnw is the time to ..tart.
• Minimise the rad iation dl""l' h' p.llil'nt" by tilking no mort' films than nl'('t'Ss,ny.
• To '*'t' fluid Irt>eIs you need fluid, ,11<1' and an t'Tt'f1 or ,huMus him, with a
horizontal X-ray beam. Su pirll' films are done with a vertical beam.
• Do not create chaos hy misinterpreting tantalum golUll'as a retained s.....ab.
• &'wal"l' of be..... el gas. It r a n hide .lny abnormality and simulate I)'lic bone
disease.
• Al......lys remember that you r clinical diagnosis m.-.y be U'7\''';{. DIl not dl·wlop
.In idee fi'ti every time ~·ou lOll\';' at a film. Remember theconcept of Jijfrrt'ntidl
diagnosis and be receptive tomformanen which may contradict your fiN
impression on the x-rays.
• The pat ients don't read the te... tbooKs - they \\;11 not always pn-ent wuh all
the symptnms and signs of a particular condition,
• Practise louking et X-ray films in boob, journals, compu ter pn'>gramml"', the
lntern et etc. and 'present' them verte uy 10 yourwlf or other medical ..lud l'ntsl
colleagues until this becomes second nature.
• Do not have J pa ssive a lt itude 10 radiograp hs. If they ar e technically
unacceptable gl't them repeated . JS long as it is clinically ;USlifil'lJ .
• Understand the limitations of X·r ay films: se nous disease ( an still be prt'St'nt

180
 Hints co n,inlJfld

with J nl'g,lliw film, but som eon e 1:'1St' mily see signs w hich yo u have no t
seen. By definition we do not kno w what we have missed - until the pust
mortem! The s anw film ran 10111. dramatically differe nt on another occasion,
or if just d little bit mort' clinical infurmafion is supplledor ano ther view is
taken .
• Remem ber that X-rolY;; litl not provide answers in en'f}' case.
• Learn to idcnn ly a cillcifit'J aorta over the spine, whether normal or
aneurysmal. This must become a n·f] "l<.
• In {'\ "t"!'Y0llt' OWl' .wcn..'Ck for Ant.·urysms. Aneurysms, Ant."UI)'sm.~- the 'triple
A' of [R. i.e.•AbJ"min.tl A"rtio.: Allt'u rpm..~ · . You mdY save ,h., f'dLitc-lII's lif"".
• Pic" d favourite organ in ,h.' abdomen that you lOCI'" for ~pt.'ddlly in I:'vt.'lj'
patien t.
• Look criticdlly dt idITll);I·nic ubjl'Cb suc h .1" nd",,-~slric tubes. Do nol a....s u me
that because tht.'y were put in by 't.'\ pt'f1s' thL~' are in the right place. Orten
t~· are nol , or Ihl'y may M\"I;' moved. Check again-..I PT\'\;OUS films .
• Sma ll fluid It'l.t>l.. can l >CCUC normally.
• Gl"t a hislory l,f any previous ..urgl'ry before trying 10 interpret any X-ray film
and make sun' you record il on the request for the radiologi..1.
• Oonol mi"lolUo a stoma for an abnormal mass .
• If time all ow.., T\' X-coly the patient atter a period of time. 10 allow an y
rad iolo~ica l change, 10 e\ ·oln>. Do not waste time with abdominal X-cays in
crincallv ill patients. If ind icated, go siraigh l 10 abdominal CT ~anning or
theatre for immt'dialt' surgical mtervennon re.g. ruptured aortic aneurysm).
• Do m>l sit rock a nd wail tor somt.'thing to JUmpnut at you from the film dod if
mllhing dOt'!> "'ll ra il il 'norm al'.
• warn the rdd il,logiral sig ns of abnormality then go looting for them
• Milk Ihe film YllU'W got bdon' dsk ing for another one.
• TIlt' d iilW1IJSis of norma lity is an important co nclusion to em ve at and is the
<lilt' Iht, patil'lll most wan ts 10 hea r.

• Go and see the rad iologbt eerty with difficult films.

• Be alert 10 incidental find ings, especia lly oulwith you r main area of interest .
These may he of even greeter importance to the patient tha n that which
you art' loo ld ng fo r. Remember that aortic aneurysms are usu ally found
incidt' ntdlly.
• Beware of slt'wids, Thl~'dru gs inr l\'aSl.' the likelihood of GI tra ct perforation
and also ma sk the sig ns.
• Wrill' X-MY Tl'l.lul'S! forms c1l',u ly, ll'gibly and provide accurate. full and all

181
 Hints COiIhn""';/

relevant clinical infnrmatiun. This will enable the rad itllt ~i~l to optimize the
dia gnosnc value tlf the film s Y~l\I MW requested. Print ytlU r ro m", and gin'
you r bleepa nd wa rd num ber clt'Jrl y, so the rad ioll~ ~t can con tact you Mc l
with Urgl'Ilt find in~... Panen ts haw d ied becau-e dectors' names were illegible
on X-ray form s, Inadequate and iII~iblt> rt'\lUNS are dangerous. mir..leading,
ol nno~in~ ol nd n~li gt'Ilt_
• Memorize a template so that ~'ou can preent .my X-ray (01"01.' H·rbally. For
example: 'This is an H.~£!!!!!!~!!.:~.:~~_Y of.~r.s.'!.'!;1..?.~!!.1.~1. taken on .~..?P~0.I.~
~.f!Q} when sht· was .?L~~~.~..~.('.~. TIlt' positive finding i~ ~.i.~!.,:~!!!~~!.~!!!'.'.~!.!!p'~~.~(
and this is consistent with a diffen-ntial diagnosis of .(!!::'.'.~.I.j.~·.li~J.I.'. and H~!!~, of
which the rno- t likl'1y is Ht:!r.!~~:~!~:!!.' Fill in the underl ined par ts depending
on you r findin~s .
Then wait fOT the croo-examrnanon.

And fin ally:

Stay cool!

182