Abdominal X-Rays for Phase 4
A Systematic Approach…
…with the clinical context
always in mind…
…avoids pitfalls!
General Approach
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Date of Film
Patient Name
Patient Age
Sex
Adequate area
covered
Topics
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Intraluminal gas
Extraluminal gas
Calcification
Soft tissues
Bones
Foreign objects
Periphery of film
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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 nondistended 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
• Centrally placed
• Narrow angle of
curvature
• Multiple loops
• Mucosal folds cross the
full width of the bowel
(valvulae conniventes)
Large Bowel
• Peripheral
• Only a few loops
• Mucosal folds only
cross part of the
bowel width (haustra)
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 /
sigmoidoscopy
• Surgical
Faecal Material
• Mottled appearance
• Wide range of normal amount
• Within large bowel
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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
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Intraluminal gas
Extraluminal gas
Calcification
Soft tissues
Bones
Foreign objects
Periphery of film
Normal structures that
calcify
Abnormal structures
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
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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
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Intraluminal gas
Extraluminal gas
Calcification
Soft tissues
Bones
Foreign objects
Periphery of film
Bone pathology
Generalised problem
Localised problem
Osteopaenia
Paget’s disease
Ankylosing spondylitis
Fractures
Osteoarthritis
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
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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
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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