PLAIN FILM

OF THE
ABDOMEN
Edi Yanuarto Hidayat
INTRODUCTION
Plain films of the abdomen are used
primarily to asses calcifications and
intestinal obstruction or perforation.
In case of acute abdomen, plain film of the
abdomen should be made in 3 positions
(Supine, upright or semi-upright, left
lateral decubitus) + chest x-ray.

SUPINE
ERECT / UPRIGHT
LEFT LATERAL
DECUBITUS
WHAT TO EXAMINE
Gas pattern
Extraluminal air / Free air
Soft tissue masses
Calcifications
NORMAL GAS PATTERN
Stomach
Almost always
Small bowel
Two or three loops of non-distended bowel
Normal diameter 3,0 cm
Large bowel
In rectum or sigmoid almost always
Normal diameter 5,0 cm
NORMAL GAS PATTERN
Gas in a few
Loops of
Small bowel
Gas in stomach
Gas in rectum
or sigmoid
NORMAL GAS PATTERN
A. Gaster
B. Colon Descenden
C. Fleksura hepatica
D. Psoas Line kiri
E. Fleksura lienalis
F. Hepar
G. Caecum
H. Sacrum
I. Os iliaca
J. Caput Femoris


THE 3,6,9 RULE
Maximum Normal
Diameter
Small bowel 3 cm
Large bowel 5 6 cm
Caecum 9 cm
It is a very useful guide to determine whether the bowel
is dilated or not.
NORMAL FLUID LEVELS
Stomach
Always
Small bowel
Two or three levels possible
Large bowel
None normally
NORMAL AIR-FLUID
LEVELS
Always air-fluid
level
in stomach
A few
Air-fluid level
in small bowel
Upright Abdomen
LARGE VS SMALL BOWEL
Characteristic Large Bowel Small Bowel
Position Circumferential the
large bowel tends to
frame the small bowel
Central
Contents Faeces of variable
consistency
Fluid like and air
Mucosal / Wall
Pattern
Haustral folds
interspaced with plica
semilunaris
Encircling valvulae
conniventes
Size Up to 5 - 6 cm, 9 cm
for the caecum
Up to 3 cm
LARGE VS SMALL BOWEL
Valvulae Conniventes Plica semilunaris and
Haustra
SMALL BOWEL
NORMAL GAS PATTERN
IN THE NEWBORN
Gas in the stomach
10 15 minutes after birth
Gas in the proximal small bowel
30 60 minutes after birth
Gas in the distal small bowel
6 hours after birth
Gas in the colon and rectum
within 12 - 24 hours after birth
ABNORMAL GAS
PATTERNS
ABNORMAL GAS
PATTERNS
A. Paralytic Ileus (Adynamic)
B. Mechanical obstruction
Small Bowel Obstruction (SBO)
Large Bowel Obstruction (LBO)
C. Localized Ileus

PARALYTIC ILEUS
Definition:
Ileus that results from hypomotility of the gastrointestinal
tract in the absence of mechanical bowel obstruction.
Symptoms & Clinical findings:
Abdominal distention
Nausea and vomiting are variably present
The bowel sounds absent or hypoactive
PARALYTIC ILEUS
Etiology:
A. Abdominal Trauma
B. Abdominal Surgery (i.e Laparatomy)
C. Serum electrolyte abnormality
Hypokalemia
Hyponatremia
Hypomagnesemia
Hypermagnesemia
PARALYTIC ILEUS
Etiology:
D. Inflammation
Intrathoracic (Pneumonia, Myocardial Infarction)
Intraabdominal (Appendicitis, Diverticulitis,
Nephrolithiasis, Cholecystitis, Pancreatitis,
Perforated duodenal ulcer)
E. Intestinal ischemia
F. Medications
Narcotics, phenothiazines, diltiazem or verapamil,
clozapine, anticholinergic.
PARALYTIC ILEUS
Radiologic findings:
Gas in dilated small bowel and large bowel to rectum
Long air-fluid levels
Bowel wall thickening

PARALYTIC ILEUS
PARALYTIC ILEUS
Differential diagnosis:
Mechanical obstruction (Ileus obstruction)
Bowel pseudoobstruction / Ogilvie Syndrome

MECHANICAL
OBSTRUCTION
Definition:
A mechanical obstruction of the bowel, preventing the
normal transit of the products of digestion.
It classifies into:
Small Bowel Obstruction (if the obstruction
occur in the level of small bowel).
Large Bowel Obstroction (if the obstruction
occur in the level of large bowel)
SMALL BOWEL
OBSTRUCTION
Symptoms & Clinical Findings:
Severe, colicky abdominal pain
Billious emesis
Mild abdominal distention
Bowel sounds:
Early: high pitched, hyperactive bowel sounds
Later: hypoactive or absent bowel sounds



SMALL BOWEL
OBSTRUCTION
Etiology:
Adhesions
Hernia
Neoplasms
Small bowel volvulus
Intussuception
Congenital anomalies (in pediatric): small
bowel atresia, small bowel stenosis, meconium
ileus

SMALL BOWEL
OBSTRUCTION
Key Concept:
Bowel distention proximal to obstruction
Bowel collapsed distal to obstruction
Radiologic findings:
Dilated small bowel > 3,0 cm in diameter
Little gas in colon
Multiple air fluid level (step ladder appearance) in
upright / LLD position
String of pearls / String of beads appearance
Coiled spring appearance

SMALL BOWEL
OBSTRUCTION
STRING OF PEARLS
APPEARANCE
- It can be seen in upright /
LLD position
- It caused by small bubbles of
air trapped in the valvulae
conniventes
STEP LADDER
APPEARANCE
White arrow is a string of
pearl appearance
COILED SPRING
APPEARANCE
It only occurs in the
dilated air-filled small
bowel
LARGE BOWEL
OBSTRUCTION
Symptoms & Clinical findings:
Emesis may occur and is brown and fecculent
Significant abdominal distention
Stool passage may be present in the early / partial
obstruction.
Obstipation in complete obstruction
Bowel sounds:
Initial: high pitched, hyperactive bowel sounds
Later: hypoactive or absent bowel sounds
LARGE BOWEL
OBSTRUCTION
Etiology:
Infectious / inflammatory
Neoplastic
Mechanical pathology
Volvulus
Incarcerated hernia
Stricture
Obstipation
In neonates: imperforate anus, meconium ileus,
hirschprung disease.


LARGE BOWEL
OBSTRUCTION
Radiologic findings:
Dilated colon to point of obstruction
Little or no air in rectum / sigmoid
Multiple air fluid level = step ladder appearance
Herring-bone appearance
Little or no gas in small bowel if ileocecal valve
remains competent.
May look like SBO, large bowel decompresses into
small bowel if ileocecal valve incompetent.
LARGE BOWEL
OBSTRUCTION
HERRING BONE
APPEARANCE
LOCALIZED ILEUS
May resemble early
SBO
SENTINEL LOOP
Supine Prone
SUMMARY FOR ABNORMAL
GAS PATTERNS
Air in rectum
or sigmoid
Air in small
bowel
Air in large
bowel
Paralytic Ileus Yes Multiple
distended loops
Yes distended
SBO No Multiple
distended loops
No
LBO No None
Unless ileocecal
valve
incompetent
Yes dilated
Localized Ileus Yes 2 3 distended
loops
Air in rectum or
sigmoid
WHAT TO EXAMINE
Gas pattern
Extraluminal air
Soft tissue masses
Calcifications
EXTRALUMINAL AIR
Signs of pneumoperitoneum:
Anterior subhepatic space air
Doges Cap Sign (free air in Morissons pouch)
Riglers sign on supine plain abdominal film
Falciform ligament sign
Footbal sign
The cupola (Air accumulation beneath the central
tendon of diaphragm)
The triangle (Air trapped between three loops of
bowel)
EXTRALUMINAL AIR
Signs of pneumoperitoneum (cont.):
Air under diaphragm on upright chest x-ray
Air outlined against liver / flank on decubitus position

ETIOLOGY
Rupture of a hollow viscus
Perforated ulcer
Perforated diverticulitis
Perforated carcinoma
Trauma or instrumentation
Post-op 5-7 days
ANTERIOR SUBHEPATIC
SPACE AIR
DOGES CAP SIGN
Doges cap sign refers to free air
in Morissons pouch
DECUBITUS ABDOMEN
SIGN
Patient in LLD
There is evidence of free
air between the
abdominal wall and the
liver (white arrow).
There is also evidence of
free fluid in the
peritoneum (black arrow).
CRESCENT SIGN
RIGLERS SIGN
The sign refer to the
appearance of the bowel
wall on the plain film
when it is outlined by
intraluminal and
extraluminal air.
The extraluminal is the
free peritoneal gas.

FOOTBALL SIGN
FOOTBALL SIGN
Massive pneumoperitoneum and
could reasonably be said to display
football sign
There is also falciform ligament sign,
Riglers sign and air in the scrotum.
FALCIFORM LIGAMENT
SIGN
If theres enough free air to outline
the falciform ligament, there is
usually enough air to also provide
Riglers sign
CONTINUOUS
DIAPHRAGM SIGN
Massive
pneumoperitoneum
CUPOLA AND LESSER SAC
GAS SIGN
White arrow: cupola sign
Black arrow: lesser sac
gas sign
There is free connection
between the lesser sac
and the greater sac
through the foramen of
winslow.
WHAT TO EXAMINE
Gas pattern
Extraluminal air
Soft tissue masses
Calcifications
SOFT TISSUE MASSES
Hepatosplenomegaly
Tumor or cyst
Bowel displacement
Paucity of gas

SPLENOMEGALY
WHAT TO EXAMINE
Gas pattern
Extraluminal air
Soft tissue masses
Calcifications
CALCIFICATIONS
Etiology:
Gallstones or renal calculi
Lymph node calcifications
Staghorn calculi
Urolithiasis
REFERENCES
www.emedicine.com
Large bowel obstruction, 2004
Colonic Obstruction, 2004
Small bowel obstruction, 2004
Bowel obstruction in the newborn, 2010
Ileus differential diagnose, 2011
Baker, R., Fischer, J., LBO, Mastery of Surgery, fourth edition, pp 1405-1407
Haubrich, W., Schaffner, F., 1995, Gastroenterology, LBO, pp 1189
www.learningradiology.com
Plain film of the abdomen
Sign in Radiology
Paul C. Nevitt. The String of Pearl Sign. Radiology 2000;214:157-158



BOWEL
PSEUDOOBSTRUCTION
Symptoms and clinical findings:
Marked abdominal distention without pain or tenderness.
Usually in elderly bedridden patient.
Etiology:
dismolity due to loss of the migrating motor complex and
bacterial overgrowth.
Radiologic findings:
isolated, proximal large bowel dilatation.
limited to colon only.

BOWEL
PSEUDOOBSTRUCTION