Unit 1

Plain Film Radiography of the Abdomen

RDSC 233

Bontrager pp. 98-116

Anatomy seen on the plain
abdomen radiograph
Radiographic anatomy

Positioning of:
Plain film abdomen (KUB), flat and:
Upright abdomen
Left lateral decubitus abdomen
Dorsal recumbant (Rt or Lt)
Maternal abdomen

Film Critique
Exposure Factors

Radiographic
Pathology
What in the World?
Miscellaneous, but significant,
odds and ends

Atlas of Human Anatomy

Third edition (260)

Need to know
Four quadrants intersect umbilicus
(RUQ, LUQ, RLQ, LLQ)
Nine regions
Right hypochondriac
Right lumbar
Right inguinal (iliac)

Epigastric
Umbilical
Pubic (hypogastric)
Left hypochondriac
Left lumbar
Left inguinal (iliac)

Atlas of Human Anatomy

Third edition (260)

Need to know
Seven landmarks
Iliac crest
Anterior superior iliac spine (ASIS}
Pubic symphysis

Greater trochanter
Xiphoid tip (T9-T10)
Inferior costal margin
Ischial tuberosity

Atlas of Human Anatomy

Third edition (245)

Need to know
Peritoneum
Falciform ligament
Diaphragm
Transversus abdominis M.*
Internal & external oblique M.*
* Muscles of the flank stripe

Atlas of Human Anatomy

Second edition (266)

Need to know
Abdominal viscera
Kidneys
Adrenal (suprarenal) glands
Pancreas (head, body, tail)
Duodenum
Rectum
Bladder
Esophagus
Aorta (left sided)
Inferior vena cava (right sided)

Atlas of Human Anatomy

Second edition (301)

Need to know
Liver
Gallbladder & bileducts
Stomach
Colon (parts of covered in colon
unit)
Spleen
Jejunum and ileum (not
shown)
Portal vein

What is normally visible

Conditions

1. Spleen
2. Gallbladder
3. Stomach
4. Veins

Y
N
Y
N

5.
6.

Arteries
Small bowel

N
if calcified
N gas is pathological

7.

Colon (gas)

with gas

8.
9.
10.
11.

Bladder
Pancreas
Ureters
Kidneys

Y
N
N
Y

with urine

12. Adrenal glands

13. Flank stripes
14. Liver

N
Y
Y

with gas

Radiographic Anatomy
Be prepared to identify these anatomical
structures in lab.

Radiographic Anatomy of
the plain film abdomen

A radiograph of the kidneys,

ureters, and bladder (KUB)
demonstrates the:
1. Size
2. Shape
3. & Position
of some, but not all the
organs in the abdominal &
pelvic cavities.
Why (in two words or less,) is
it difficult to differentiate
abdominal organs, and not
possible to visualize others
at all?

Subject Contrast

An old term was

flat plate of the abdomen

Radiographic Anatomy of
the plain film abdomen

What is normally visible

1.
2.
3.
4.
5.
6.
7.

Liver
Spleen
psoas muscles
kidneys
flank stripes
bone (like crazy)
Calcifications

What is sometimes visible

1. Stomach and colon (gas)
2. Bladder (urine filled)
3. Arteries (calcified aorta)
What is not visible
1. Gallbladder
2. Pancreas
3. Small bowel (unless
pathological, with gas)
4. Ureters
5. Adrenal glands
6. Veins
7. Everything else

Liver (homogeneous
shadow in RUQ)
Spleen
Stomach (c gas)
Parts of colon (c gas)
hepatic flexure
transverse colon
cecum & ascending colon
Gas, though natural,
is a negative contrast
media. In the history
of radiography, gas (air)
was injected in the bladder
and ventricles of the brain.
Carbonated soda is given
to children to create a
window to the kidneys
Radiographic Anatomy of the plain film abdomen

Radiographic Anatomy of
the plain film abdomen

More Gas
Patterns

A childs stomach
and colon filled with
gas and feces, (speckled
appearance).
Note how the hepatic
flexure and transverse
colon define the liver

Gas filled transverse

colon demonstrating
haustrations.

Entire colon, from

cecum to sigmoid,
filled with gas.
Unless obstructed,
distention of this
degree should be
relieved by
flautulence

Detail of liver in RUQ

Radiographic Anatomy of
the plain film abdomen

Detail of spleen in LUQ

Detail of flank stripe

Detail of urine filled bladder

Radiographic Anatomy
of the plain film
abdomen

Flank stripes are not

always seen due to
lack of contrast or
clipping on larger
persons.
When visible, bowing
of the stripes may
be a sign of a mass.

The bladder is
often seen, if
contrasted by
urine.
Gas in the
sigmoid colon
may obscure it

Radiographic Anatomy of the plain

film abdomen

Kidneys
Subject contrast of the
kidneys is enhanced by the
perirenal fat capsule. They
are best seen in the asthenic
body habitus

= Psoas muscles
Placement of Rt marker is less than desirable

Calcifications

Radiographic Anatomy of the plain

film abdomen

Calcifications can form

in various tissues, and
especially fluid filled
organs where minerals
consolidate. In the
plain film abdomen
those seen are:

Large gallstone in RUQ

If not in the RUQ, where else could it be?

* gallstones (calcium
not cholesterol)
* kidneystones
* bladderstones
* arteriosclerosis
(mostly of abdominal
aorta)

Anatomy Review: Where is it, or, at least, where should it be?

Radiographic Positioning of the Abdomen

Positioning of:
AP KUB (flat plate of the abdomen)

Upright abdomen
seated or standing
Left lateral decubitus

including

Film Critique
Beginning with the routine KUB
Review the ARRT Standard Terminology
for Positioning and Projections

Standard KUB Positioning

But first, when using the

bucky
1. Put the tube in detent
And leave it alone
2. Align the tube to the bucky
(longitudinally)
And leave it alone*

3. Put a film in the bucky, mark it, close the tray

And leave it alone
4. To position, float the table, move the patient, but
dont disturb steps 1-3
5. Shield
When positioning in lab, follow these steps. Someone will critique your efficiency

*If views in a routine require angles, do them last if possible.

Standard Abdomen Positioning

Preparation
1. Evaluate the order
2. Greet the patient
3. Take History
Plain film radiography of the abdomen
may be used to diagnose acute
abdomen, or provide preliminary
information for further studies.
Pertinent Hx includes:
Abdominal pain: chronic or acute,
location (quadrant or region). Times?
(i.e. after eating). Previous hx? Known
cause? Bloating, constipation, diarrhea.

4. Remove jewelry, check attire, snaps, pins, NG tubes, etc.

5. Explain the exam in laymans terms
6. Questions?
7. Set technique before positioning

Routine KUB Positioning

Setup

1. 40 SID (relatively standard)

2. Reciprocating bucky
12:1, 16:1 grid
3. 70-80 kVp range
4. 14 x 17 film, lengthwise
5. ID marker at bottom
6. Rt marker above ID marker

Routine KUB Positioning

Positioning
1. CR to iliac crest
2. Entire spine
straight
3. No rotation on hips
(check ASIS)

4. Arms away from sides (with sheet covering

patient, watch for wandering hands)
5. Exposure at end of respiration (hold it)

Film Critique for KUB film

* Patient ID
* Rt/Lt, special marker
* Contrast & density
* Motion *
* Artifacts
Clipping: Superior ramus and
pubic symphysis must be
included.

Centering (left to right)

including
Rotation: Ala of ilium are
symmetrical. Vertebral bodies
are vertical (no side bending)
and not rotated.
* Peristalic activity may create
motion of the gas pattern.

KUB Positioning: 2 films method

When the patient is tall, two films
used lengthwise may be necessary.
When the patient is wide, two
transverse.
Note the overlap
as evidenced by
the iliac crest

Take first exposure of the pelvis.

After changing films, place finger on
top of light field, float table top
to the the upper abdomen collimated
field overlaps the previous field by
3 or 4 inches.

Non routine positions:

Upright abdomen
Left lateral decubitus
Dorsal recumbant decubitus

Routine Upright Positioning

Setup and Preparation

Same as supine, expect upright.
And, patient must be in position
for at least 5 minutes prior to
exposure. Bring by WC if possible

4.

CR

Positioning
1. Same as KUB,
but center top
of film to axilla.

Standard Upright Abdomen Positioning

What (else) does the upright

demonstrate?
1. Air-fluid levels in the
bowel
2. Free air in the abdomen
(peritoneal cavity) under the
diaphragm

Residual barium x 3 weeks

3. Ptosis (Change in position)

Might a change in technique be
called for on the upright?

Standard Upright Abdomen Positioning

Criteria: In addition to the

criteria for a supine KUB, the
upright film must demonstrate
lung tissue above the diaphragms
and plenty of it. Visualizing the pelvic
cavity to the symphysis is not criteria

Standard Left Lateral Decubitus Positioning

The left lateral

decubitus film is done
when the patient is unable
to stand or sit.

Flash marker

Set up/Positioning

CR

Same as for the upright, except

the grid film is in a film holder
(not a reciprocating bucky)

Sponge

Check the patients

measurement. Too
many double bacon
cheeseburgers may
make it like this

Lt flank

Rt flank

A horizontal beam projection to demonstrate free air, and air fluid levels.

A left lateral, and only a left lateral, is the decubitus position

because of the air bubble that is normally in the stomach

Standard Left Lateral Abdomen Positioning

Whats the big deal with the stomach bubble?

To evaluate free air, it is important to not have the
stomach bubble under the flank stripe.
Rt side

Criteria: Mid portion

of the abdomen, along

the flank (not symphysis
or diaphram) visible.

Iliac crest

Stomach bubble

Dorsal decubitus (Rt or Lt) Abdomen Positioning

The dorsal
decubitus film is done when that
position is all the patient is able
to tolerate, or for evaluation of
the aorta in arteriography

Flash marker

Set up/Positioning
CR

CR

Sponge

Same as for the decubitus

A horizontal beam projection
to demonstrate free air, and
air fluid levels.

In the dorsal decubitus position free air layers out under the
anterior abdominal muscles. Air fluid levels, and the
abdominal aortic aneurysms may be seem, but due to part
thickness, this projection is not optimal.

Review of Abdomen film Critique

The KUB film must demonstrate all anatomy within the
abdominal cavity
The upright, left lateral decubitus, and dorsal
decubitus positions demonstrate free air, and air-fluid
levels.
The upright also demonstrates ptosis of the abdominal
organs.

On all films
Patient ID
Rt or Lt marker
Contrast & density
Motion
Artifacts

Exposure Factors
From the Rules of Thumb
Based on: 3 phase, 100 RS film, 12:1 grid, 40 SID
Abdomen/Pelvis
Frontal
(2 x cm) + 35 =kVp @ 50 mAs
Lateral

(4x frontal)

(AP + 10 kVp

@ 100 mAs

Oblique
(AP + 40% - 60% of frontal
technique

Exposure Factors
From the Rules of Thumb
Based on: 3 phase, 100 RS film, 40 SID
Maternal Abdomen
On occasion a radiograph of the pregnant
abdomen is ordered during labor, to check
for a breech presentation.

Every radiology department should

have at least one high speed
film/screen system for this purpose.
What is required in terms of kVp and
mAs?
High kVp (110 or higher), low mAs.

Exposure Factors
From the Rules of Thumb
Based on: 3 phase, 400 RS film, 40 SID
Calculate a maternal abdomen
technique for a 35 cm measurement
1. (2 x 35) + 35 = 105 kVp @ 50 mAs
2. 40 mAs / 4 = 12.5 mAs (film speed)
3. 15% of 105 = 16.5 =
Answer 121 kVp @ 6 mAs
Critique critera: For presentation, only
gross anatomy need be visualized.
Maternal abdomen films are rarely
repeated.

Significant Pathologies or Pathologic Indicators

of the abdomen
and their

Radiographic Appearances

Mass
Institutional colon
Pneumoperitoneum

Ascites

Ileus

An example of how the knowledge of the normal size, shape, and position
of abdominal anatomy is used to diagnose disease on a KUB.
This film demonstrates a bowing of the right psoas muscle, and increased
opacity. The diagnosis was abdominal aortic aneursym (AAA), unusual in
that it is on the right, rather than the left, where the aorta is.

Another example: size, shape, or position.

10 cm mass on the
right of midline
In the right lumbar
region

Normal variants If a mass is not pathologic, it may be an anomaly.

The detail in this LUQ shows anatomy not normally
seen there. Lateral to the kidney, only the stomach,
spleen, and colon are expected possibilities.
The radiologist determined this to be the
tongue of the liver (long tip of left lobe),
interposed between the spleen and splenic
flexure

Institutional Colon
Fecal stasis or fecal
impaction are terms that
describe what is commonly
called constipation.
Institutional colon in found in
bedridden, elderly patients,
whose eliminations
have not been monitored

Pneumoperitoneum
Diaphragm

Air in the abdominal cavity,

(outside of the alimentary
tract) comes from perforated
viscus, a puncture wound, or
recent surgery.
Gastric or duodenal ulcers
can perforate and allow air
and stomach contents to
escape, leading to peritonitis

Liver
Stomach

In the upright position free air layers out under the

diaphragm. Large quantities may be obscured if
the top of the film is not high enough.
Free air

Stomach bubble

Ascites

Fluid accumulation in the

abdominal cavity, secondary
to serious disease.
Ascites creates a gray, low
contrast effect, and as in this
film, may make gas in the
bowel look trapped, or encased
by the extrinsic pressures from
the fluid.

Ileus

An ileus is a failure of intestinal

contents to move through the
bowel, for reasons catagorized as
Mechanical ileus: caused by a
physical obstruction such as a
tumor, adhesions, volvulus
(twisting) intussusception
(telescoping), or hernia.
Dynamic ileus: muscular constriction
Adynamic ileus: lack of motility, paralytic

Gallstone ileus
Postoperative ileus

Gas in the stomach, normal from aerophagia,

is relieved by eructation. Gas in the colon,
normal from the action of e-coli, is relieved
High grade mechanical obstruction. Gas by flatulence. Gas in the small intestine is
pathological.
avoids pelvis indicating possible mass.

Ileus
Gas in the colon, normal from the
action of e-coli, is relieved by
flatulence.
Gas in the small intestine is
pathological.

Mild to moderated ileus. In addition to distention of

the colon, note the gas pattern in the small bowel

What in the World?

Miscellaneous, but significant, odds and ends

What in the World?

Identifying ingested or inserted

foreign bodies are another
use for the KUB film

What in the World?

Badmitton champion presents
with abdominal pain.
This Greenfield caval filter is in
the inferior vena cava for the
purpose of catching clots from
leg veins. If the filter were not
present, clots would travel to the
right heart, pulmonary artery, and
the arterioles of the lungs,
causing pulmonary embolism.
(Kidding about the badmitton)

What in the World?

There is something odd

about the gas pattern
In the area of the sigmoid
colon
And its shaped like a tooth
brush holder

What in the World?

Is this Melvin the
Moonman, or...
A Cheese Whiz
jar UTB

What in the World?

Illustration from The Compete
Idiots Guide to Home Medical
Treatment, or what?

The End

Quiz 1

Name the 9 regions

of the abdomen
and pelvis

Y ( if needed to see) or N

What can be visualized

10.
11.
12.
13.
14.
15.
16.
17.
18.
19.

Gas?

Urine?

Spleen
Gallbladder
Adrenal glands
Stomach
Veins
kidneys
Colon (gas)
bladder
Pancreas
Ureters

Liver

Sm. Bowel

Y
Y

N
Y

N
N