Abdominal x rays made easy: normal radiographs The standard abdominal radiograph (AXR) taken is a supine projection: o x rays

s are passed from front to back (anteroposterior projection) of a patient lying down on his or her back. n some circumstances an erect AXR is re!uested: o its ad"antage o"er a supine film is the "isualisation of air#fluid le"els. A decubitus film (patient lying on his or her side) is also of use in certain situations. Although an AXR is a plain radiograph$ it has a radiation dose e!ui"alent to %& posteroanterior chest x rays or si' months of standard background radiation. As with any plain radiograph$ only fi"e main densities are seen$ four of which are natural: o black for gas$ o white for calcified structures$ o grey representing a host of soft tissue with a slightly darker grey for fat (as it absorbs slightly fewer x rays). o (etallic objects are seen as an intense bright white. The clarity of outlines of structures depends$ therefore$ on the differences between these densities. )n the chest radiograph$ this is easily shown by the contrast between lung and ribs##black air against the white calcium containing bones. These differences are much less apparent on the AXR as most structures are of similar density##mainly soft tissue.

*igure +. ,ormal film

Technical features t is important$ as with any image$ that the technical details of an AXR are assessed. The date the film was taken and the name$ age$ and se' of the patient are all worth noting. This ensures you are interpreting the correct film with the correct clinical information and it also may aid your interpretation.

,e't ask what type of AXR is it: supine$ erect$ or decubitus- .nless specifically labelled the film is taken to be supine. The best way to appreciate normality is to look at as many films as possible$ with an awareness of anatomy in mind (fig +). Intraluminal gas /egin by looking at the amount and distribution of gas in the bowels (intraluminal gas). There is considerable normal "ariation in distribution of bowel gas. )n the erect AXR$ the gastric gas bubble in the left upper !uadrant of the film is a normal finding. 0as is also normally seen within the large bowel$ most notably the trans"erse colon and rectum (fig 1).

*igure 1. Rectal gas film mportant characteristics of bowel loops to bear in mind are their si2e and distribution (where they are situated in relation to other structures). o Normal small bowel should measure less than 3 cm in diameter, o normal colon should measure less than 5 cm in diameter . o The diameter of the caecum may be greater$ but if it is greater than 3 cm it is abnormal. o 4arge bowel should lie at the periphery of the film$ with small bowel distributed centrally. o 5mall and large bowel can also be distinguished$ most easily when dilated$ by their different mucosal markings. o 5mall bowel has "al"ulae conni"entes that trans"erse the full width of the bowel6 o large bowel has haustra that cross only part of the bowel wall (figs 7 and 8). o )ccasionally$ fluid le"els in the small bowel are a normal finding

. *igure 7. 9al"ulate conni"entes

*aecal matter in the bowel gi"es a :mottled: appearance (fig %). This is seen as a mi'ture of grey densities representing a gas#li!uid#solid mi'ture. Extraluminal gas laces to loo! for abnormal extraluminal gas

.nder the diaphragm n the biliary system ;ithin the bowel wall

0as outside the bowel lumen is in"ariably abnormal. The largest "olume of gas you might see is likely to be under the right diaphragm: this occurs after a "iscus has been perforated. This gas within the peritoneal ca"ity is termed pneumoperitoneum. 0as in the right upper !uadrant within the biliary tree is a :normal: finding after sphincterotomy or biliary surgery$ but it can indicate the presence of a fistula between the biliary tree and the gut.

*igure 8. <austra films /eware of gas in the portal "ein$ as this can look "ery similar to biliary air. 0as in the portal "ein is always pathological and fre!uently fatal. t occurs in ischaemic states$ such as to'ic megacolon$ and it may be accompanied by gas within the bowel wall (intramural gas).

*igure %. *aecal mottling "alcification =alcium is "isible in a "ariety of structures$ both normal and abnormal$ and becomes more common with ad"ancing age. <owe"er$ re"iew the following areas in particular for e"idence of calcification: o o o o o cartilage of ribs$ blood "essels (chiefly the aortoiliac and splanchnic arteries)$ pancreas$ kidneys$ the right upper abdominal !uadrant for gallbladder calculi$ and the pel"is$ which may contain a "ariety of calcified structures$ most commonly phleboliths. >art 8 of this series is dedicated to calcification on AXR.

*igure ?. pseudotumour #oft tissues and bone

0astric

A re"iew of the soft tissues entails e"aluating the outlines of the major abdominal organs. )bser"ing these structures is made easier by the :fatty: rim (properitoneal fat lines) surrounding them. n fact$ the loss of these fat planes may indicate an ongoing pathological process$ such as peritonitis. 4ook at the si2e and position of the li"er and spleen. 4ook at the position and si2e of the kidneys$ lateral to the midline in the region of the T+1#41 "ertebrae (a useful way of identifying "ertebrae: the lowest one to gi"e off a rib is T+1

and ser"es as a reference point). The renal outline is usually three to three and a half "ertebral bodies in length. Also$ look for the clear outline of the psoas muscle shadow(s). *inally$ try to identify the outline of the bladder$ seen more clearly if full$ within the pel"is. The appearance of what looks like a soft tissue mass in the region of the stomach is more often than not actually a gastric pseudotumour. This is a normal finding on the supine film and represents gastric fluid lying within the fundus (fig ?). The assessment of bones entails e"aluating the spine and pel"is for e"idence of bony pathology. )steoarthritis fre!uently affects the "ertebral bodies$ as well as the femoral and the acetabular components of the hip joint. >aget@s disease may also be identified$ commonly along the iliopectineal lines of the pel"is. Aour bone sur"ey should also check for fractures$ especially subtle femoral neck fractures in elderly people. The spine and pel"is are also common locations for metastatic deposits. n the spine this is classically seen as :the absent pedicle.: resenting the A$% This is the supine abdominal radiograph of a 81 year old women taken yesterday. t is technically satisfactory. The amount and distribution of gas within the bowel is normal. There is no bowel dilatation. There is no e"idence of e'traluminal air. 5oft tissue outlines of the psoas muscles and kidneys are seen. The kidneys are normal in si2e and shape. There are no apparent bony lesions or abnormal calcification. ncidentally$ sterilisation clips can be seen within the pel"is indicating pre"ious gynaecological inter"ention.