ABDOMINAL X‐RAY

BY ABDULLAH ASA’AD
 ABDOMINAL X‐RAY

• INCLUSION:
• THE ENTIRE ANATOMY SHOULD BE INCLUDED FROM
THE HEMI‐DIAPHRAGMS TO THE SYMPHYSIS PUBIS.

• NORMAL ABDOMINAL RADIOGRAPH SHOWING

THE:
1. SUPERIOR ASPECT OF THE LIVER .
2. SUPERIOR ASPECT OF THE SPLEEN .
3. LATERAL ABDOMINAL WALLS .
4. THE PUBIC SYMPHYSIS
ABDOMINAL X‐RAY
GENERAL
Air/gas Black

Fat Dark grey

Soft tissues or Light grey

fluid

Contrast material Off-white

Bone Bright white

 ABDOMINAL X‐RAY
ANATOMY
1. SOLID ORGANS
1. LIVER
2. SPLEEN
3. PANCREAS ( NORMAL
WE CAN’T SEE IT)

Air in stomach
 ABDOMINAL X‐RAY
ANATOMY
2. KIDNEY AND URETER AND
BLADDER.
1. R KIDNEY 2. L KIDNEY
3. SITE OF R URETER 4. SITE OF
L URETER (NOT NORMALLY
VISUALIZED )
5. BLADDER
6. AIR IN RECTUM
7. +8 SITE OF ADRENAL GLAND
(NOT NORMALLY VISUALIZED)
9. SITE OF GALL BLADDER (NOT
NORMALLY VISUALIZED).
• IN THESE PIC WE SEE NORMAL
VISUALIZED ORGANS & BONES IN AXR.
 ABDOMINAL X‐RAY
ANATOMY
3. SOLID ORGANS
1. LIVER
2. SPLEEN
3. PANCREAS ( NORMAL
WE CAN’T SEE IT)

Air in stomach
 ABDOMINAL X‐RAY
ANATOMY
1. BOWEL
• THE ROLE OF BOWEL IN AXR NOTHING FIXED !!
1. STOMACH
2. CAECUM
3. ASCENDING COLON
4. HEPATIC FLEXURE
5. TRANSVERSE COLON
6. SPLENIC FLEXURE
7. DESCENDING COLON
8. SIGMOID COLON
• NOW GO TO MORE EX. OF BOWEL IN AXR AND
SOME CHARACTER OF LARGE AND SMALL BOWEL
 Normal bowel
ABDOMINAL X‐RAY
ANATOMY
Normal bowel
 ABDOMINAL X‐RAY
ANATOMY
LARGE BOWEL
1. SITE PERIPHERALLY.
2. THE COLONIC WALL IS LINED BY HAUSTRA
3. UP TO 6 CM IN DIAMETER.
4. CONTAINS GAS AND FAECES.

• ‫انصاف حلقات متداخله‬

 ABDOMINAL X‐RAY
ANATOMY
SMALL BOWEL
1. SITE CENTRALLY .
2. VISIBLE VALVULAE CONNIVENTES
3. UP TO 3 CM IN DIAMETER
4. ONLY CONTAINS GAS LESS THAN LARGE

• ‫بكون حلقات كاملة‬

 WHAT TO LOOK FOR IN AN AXR
First, look at the overall gas patter, You are looking for the overall
pattern, so do not spend too much time trying to identify every
bubble of bowel gas you see.
Second, check to see if there is Extraluminal air.
Third, look for abnormal abdominal calcifications.
Fourth, look for any soft tissue masses.

1. BOWEL GAS PATTERN 4. SIGNS OF INTESTINAL

OBSTRUCTION
2. RADIO-OPAQUE STONES OR
CALCIFICATION 5. SKELETAL ABNORMALITIES

3. EXTRA LUMINAL FREE GAS 6. AIR FLUID LEVELS

 AIR !
INTRALUMINAL / EXTRALUMINAL
• NORMAL INTRALUMINAL GAS
1. STOMACH : ALWAYS
2. SMALL BOWEL : TWO OR THREE LOOPS OF NON-DISTENDED
BOWEL
3. LARGE BOWEL : ALMOST ALWAYS IN RECTUM/SIGMOID
 PNEUMOPERITONEUM
AIR UNDER DIAPHRAGM \FREE GAS IN THE PERITONEAL CAVITY

MAIN CAUSES :
1. PERFORATED PEPTIC ULCER
2. PERFORATED APPENDIX/BOWEL
DIVERTICULUM We find it at RT. Side because the left is obscured by the stomach
3. POST‐SURGERY
4. TRAUMA

diaphragm
The normal is no air
(black ) under it )
 PNEUMOPERITONEUM
FREE GAS IN THE PERITONEAL CAVITY

double‐wall sign (Rigler’s sign )

in supine AXR we lock for double

wall sign not under diaphragm, the air
go up !!!
EX. FROM LECTURES, BOOKS, GOOGLE AND PAST JASMINE NOTE

Gas outlining both

sides of the bowel
wall in keeping with
Rigler’s sign
EX. FROM LECTURES, BOOKS, GOOGLE AND PAST JASMINE NOTE
Air under diaphragm

diaphragm
The normal is no air
(black ) under it )
 PNEUMORETROPERITONEUM
GAS IN THE RETROPERITONEAL SPACE
• RETROPERITONEAL CONTAINS THE KIDNEYS, URETERS, ADRENAL GLANDS, AORTA, INFERIOR
VENA CAVA (IVC), MOST OF THE PANCREAS DUODENUM, THE ASCENDING AND DESCENDING
COLON.
• THE CAUSES :

1. BOWEL PERFORATION :
• POSTERIOR DUODENAL PERFORATION
• ASCENDING OR DESCENDING COLON PERFORATION
• RECTAL PERFORATION
2. POST‐SURGICAL (E.G. RESIDUAL AIR FROM
UROLOGICAL/ADRENAL/SPINAL SURGERY)
 PNEUMORETROPERITONEUM
GAS IN THE RETROPERITONEAL SPACE
• THE KEY TO IDENTIFYING A PNEUMORETROPERITONEUM IS TO LOOK FOR GAS
(BLACKNESS) SURROUNDING ALL OR PART OF THE KIDNEYS.

Kidney
 DILATED SMALL BOWEL
SMALL BOWEL OBSTRUCTION
• DISTENSION OF THE SMALL BOWEL IS A SIGN OF MECHANICAL OBSTRUCTION OR ILEUS. IN A
NORMAL INDIVIDUAL THE SMALL BOWEL IS NOT VISUALIZED BECAUSE IT IS COLLAPSED OR
CONTAINS FLUID.
• MECHANICAL OBSTRUCTION AND ILEUS APPEAR IDENTICAL :
1. DILATION >3 CM (THE HEIGHT OF AN ADULT VERTEBRAL BODY IS APPROXIMATELY 4 CM
,COMPARE TO IT )
2. CENTRAL LOCATION.
3. VALVULAE CONNIVENTES ; THEY ARE THIN, CLOSELY SPACED AND CLASSICALLY SEEN AS A
CONTINUOUS THIN LINE ACROSS THE ENTIRE WIDTH OF THE BOWEL.
EX. FROM LECTURES, BOOKS, GOOGLE AND PAST JASMINE NOTE

• DILATED BOWEL LARGE OR SMALL ?

• CENTRALLY , DILATED MORE THAN 3 CM ,
AND VALVULAE CONNIVENTES CAN BE
SEEN

• SO
• SMALL BOWEL
OBSTRUCTION
EX. FROM LECTURES, BOOKS, GOOGLE AND PAST JASMINE NOTE
Small Bowel Obstruction

• VISIBLE VALVULAE CONNIVENTES .

• CENTRALLY POSITION.
• DILATED
 DILATED LARGE BOWEL
LARGE BOWEL OBSTRUCTION
• LARGE BOWEL DISTENSION IS ALMOST ALWAYS DUE TO LARGE BOWEL OBSTRUCTION. THE
BOWEL PROXIMAL TO THE OBSTRUCTION IS DILATED AND THE BOWEL DISTAL TO THE
OBSTRUCTION IS USUALLY COLLAPSED.
• RADIOGRAPHIC APPEARANCES:
1. DILATION >5.5 CM; EXCEPT CECUM ABOVE 9 CM TO CALLED DILATE
2. PERIPHERAL LOCATION.
3. HAUSTRA: THICK, WIDELY SPACED AND DO NOT CROSS THE ENTIRE WIDTH OF THE BOWEL.
EX. FROM LECTURES, BOOKS, GOOGLE AND PAST JASMINE NOTE

• DILATED BOWEL LARGE OR SMALL ?

• PERIPHERALLY , DILATED MORE THAN
VERTEBRA ABOUT DOUBLE 8CM , AND
HAUSTRA CAN BE SEEN SPACED .

• SO
• LARGE BOWEL
OBSTRUCTION
EX. FROM LECTURES, BOOKS, GOOGLE AND PAST JASMINE NOTE

haustra

• LARGE BOWEL
OBSTRUCTION
dilated bowel
EX. FROM LECTURES, BOOKS, GOOGLE AND PAST JASMINE NOTE

• LARGE BOWEL
OBSTRUCTION
haustra

dilated bowel
 VOLVULUS
TWISTING OF THE BOWEL
• A VOLVULUS IS THE TWISTING OF THE BOWEL ON ITS MESENTERY. IT CAUSES PARTIAL OR
COMPLETE BOWEL OBSTRUCTION.
• 2 TYPES 1. SIGMOID , 2. CECAL .
A. RADIOLOGICAL SIGNS OF A SIGMOID VOLVULUS:
1. COFFEE BEAN SIGN: THE SHAPE OF THE DISTENDED GAS FILLED ‘CLOSED LOOP’ OF COLON
LOOKS LIKE A LARGE COFFEE BEAN.
2. GENERAL LACK OF HAUSTRA: OFTEN THE BOWEL IS SO DISTENDED THAT HAUSTRA FLATTEN
OUT
3. DISTENSION OF THE ASCENDING, TRANSVERSE AND DESCENDING COLON
B. Radiological signs of a caecal volvulus:
1. Comma shaped: The shape of the distended gas filled ‘closed loop’ of colon often looks like a
large comma
2. Haustra often visible
3. Collapse of the ascending, transverse and descending colon: The colon distal to the obstruction
(volvulus) is often collapsed.
 VOLVULUS
TWISTING OF THE BOWEL
cecal sigmoid
 EX. FROM LECTURES, BOOKS, GOOGLE AND PAST JASMINE NOTE

sigmoid volvulus
Coffee bean sign
general lack of haustra
 EX. FROM LECTURES, BOOKS, GOOGLE AND PAST JASMINE NOTE

Caecal volvulus
Comma , not like coffee .
In RT. Pic haustra clearly
seen
Other part of colon
collapse.
 INFLAMMATORY BOWEL DISEASE
IMPOSSIBLE TO DIFFERENTIATE BETWEEN THE DIFFERENT CAUSES
OF COLITIS USING A PLAIN ABDOMINAL RADIOGRAPH
• BOWEL WALL INFLAMMATION CAN OCCUR ANYWHERE ALONG THE
BOWEL, BUT IS MOST COMMONLY SEEN IN THE LARGE BOWEL.
• RADIOLOGICAL SIGNS OF WALL INFLAMMATION :
 BOWEL WALL THICKENING : DUE TO MUCOSAL OEDEMA.
1. THUMB PRINTING (‘THUMB‐SHAPED’) : HAUSTRA THICKENING TO GO
LIKE THUMB.
2. FEATURELESS BOWEL ( PIPE – SHAPED ) : WHEN THICKENING WALL
LOST ALL FUTURE OF COLON .

Normal Thumb shaped

Futureless or pipe shaped

From lecture
EX. FROM LECTURES, BOOKS, GOOGLE AND PAST JASMINE NOTE

THUMP SHAPED

FATHERLESS
EX. FROM LECTURES, BOOKS, GOOGLE AND PAST JASMINE NOTE

LARGE BOWEL PIPE SHAPE

SMALL BOWEL NARROWING

AND WE NO UC NOT SEEN IT IN SMALL BUT CD THE
LOVELY SITE
 INFLAMMATORY BOWEL DISEASE

SITE !
SKIP LESIONS
RECTUM VS ILEUS
 TOXIC MEGACOLON

• TOXIC MEGACOLON IS AN ACUTE FORM OF BOWEL DILATATION OCCURRING AS A COMPLICATION

OF INFLAMMATORY BOWEL DISEASE (ULCERATIVE COLITIS OR CROHN'S) OR INFECTION .
• RADIOLOGICAL SIGNS :
1. LARGE BOWEL DILATATION
2. INFLAMMATORY PSEUDO POLYPS
3. THUMBPRINTING AND MUCOSAL OEDEMA MAY BE PRESENT
4. USUALLY TRANSVERSE COLON AFFECTED
EX. FROM LECTURES, BOOKS, GOOGLE AND PAST JASMINE NOTE

Toxic Megacolon
 DIVERTICULOSIS
• POLYPS LIKE

LARGE BOWEL

LIKE POLYP
‫كمشة صور مشكلة ‪‬‬
• CENTRALLY
• DILATED =
VERTEBRA .
• VALVULAE
CONNIVENTES

• SMALL BOWEL
OBSTRUCTION
sigmoid volvulus
Liver enlargement
Urine catheter

Nasogastric tube
nasojejunal tube
Gastric band
device
‫النهاية‬