Abdominal X-Rays for Phase 4

A Systematic Approach
with the clinical context
always in mind
avoids pitfalls!
General Approach
 Date of Film
Patient Name
Patient Age
Sex
Adequate area
covered
 Topics

Intraluminal gas
Extraluminal gas
Calcification
Soft tissues
Bones
Foreign objects
Periphery of film
 Intraluminal gas
Extraluminal gas
Calcification
Soft tissues
Bones
Foreign objects
Periphery of film
 Normal Intraluminal Gas
Stomach : Always
Small Bowel : Two or three loops of non-
distended bowel
Normal diameter < 3.5 cm (jejunum)
Normal diameter < 2.5 cm (ileum)
Large Bowel : Almost always in rectum/sigmoid
Normal diameter < 5 cm (colon)
Normal diameter < 9 cm (caecum)
 Stomach gas

Gas in
ascending
colon Gas in a few
loops of
small bowel

Gas in
rectum
 Large or small bowel?
Small Bowel Large Bowel

Centrally placed
Peripheral
Narrow angle of
curvature Only a few loops
Multiple loops Mucosal folds only
Mucosal folds cross the cross part of the
full width of the bowel bowel width (haustra)
(valvulae conniventes)
Small Bowel Obstruction

Mucosal folds
go all the way
across
Mucosal folds
only partly
cross bowel
wall

Peripheral loop of
caecum
Large Bowel Obstruction
Some reflux of
air into
terminal
ileum
Where is the level of obstruction?
 Distal descending colon
cancer proven at barium enema
 32 year old patient, poorly controlled
ulcerative colitis, presenting with bloody
diarrhoea and severe abdominal pain
Very dilated transverse colon
(>6cm)
Oedematous mucosa descending
colon (thumbprinting)
 Toxic Megacolon

SURGICAL EMERGENCY
 Very dilated large bowel

Haustral folds do not

cross all the way across
Normal gas pattern in
ascending colon and
caecum
 Apex of loop in left
upper quadrant

Sigmoid Volvulus
Very dilated large bowel
Normal descending colon
 Apex of loop
centrally / left
upper quadrant
Caecal Volvulus
 Management of Volvulus
Sigmoid Caecal

Trial of flatus tube / Surgical

sigmoidoscopy
 Faecal Material
Mottled appearance
Wide range of normal amount
Within large bowel
 Intraluminal gas
Extraluminal gas
Calcification
Soft tissues
Bones
Foreign objects
Periphery of film
 Extraluminal Gas
Invariably abnormal

Exceptions
Recent laparotomy / laparoscopy (<5 days)
Gas in biliary tree after biliary intervention

Only seen if large (>1 litre) amount of

gas
Can see both sides
of the bowel wall

Gas outlining
peritoneal
cavity
Pneumoperitoneum
Erect Chest X-ray is the best
initial test for excluding
perforation
Pneumoperitoneum

Free gas under diaphragm

Pneumoperitoneum
Lateral decubitus view
Free intraperitoneal gas
 Intraluminal gas
Extraluminal gas
Calcification
Soft tissues
Bones
Foreign objects
Periphery of film
 Normal structures that Abnormal structures
calcify containing calcium

Costal cartilage Pancreas

Mesenteric lymph nodes Blood vessels/aneurysms
Pelvic vein clots (phleboliths) Uterine fibroids
Prostate gland Calculi:
Biliary
Bladder
Renal
Gallstones
Renal Calcification
Calculi also within left ureter
Bladder stones
Calcified
Aortic
Aneurysm
 Pancreatic
calcification
 Intraluminal gas
Extraluminal gas
Calcification
Soft tissues
Bones
Foreign objects
Periphery of film
 Soft Tissues
AXR relatively insensitive unless very
large enlargement

May see bowel displacement

 Bowel loops displaced

Large pelvic mass

 2 hours later

.after bladder
catheterisation
 Intraluminal gas
Extraluminal gas
Calcification
Soft tissues
Bones
Foreign objects
Periphery of film
 Bone pathology

Generalised problem Localised problem

Osteopaenia Fractures
Pagets disease Osteoarthritis
Ankylosing spondylitis Metastatic deposits

abnormalities may be coincidental

Clue : 77 year old with known colon cancer
and lower back pain
Sacral metastasis
Ankylosing Spondylitis

Bamboo spine

Fused sacro-iliac
joints
 Intraluminal gas
Extraluminal gas
Calcification
Soft tissues
Bones
Foreign objects
lightbulbs toothbrush
 Other foreign objects
Sterilisation Clips
Should both lie in the pelvis
Surgical Clips
Cholecystectomy
Hip prostheses
Retained swabs / needles very rare
 Intraluminal gas
Extraluminal gas
Calcification
Soft tissues
Bones
Foreign objects
Periphery of Film
 Periphery of Film
Lung bases
Hernial orifices
Subcutaneous tissues
Small and large bowel obstruction

Strangulated right inguinal

hernia
 Summary

Clinical context is very important

Remember to have a systematice approach

 CXR Tutor
series of 9 self-directed learning presentations on
Medi-CAL site

Includes tubes and lines, lung cancer, pneumothorax,

interstitial lung disease and a quiz
The End